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Filip Teodor



Affects of Prenatal alcohol exposure

According to a study presented today at the annual meeting of the Radiological Society of North America (RSNA), alcohol consumption during pregnancy affects the nervous system of the fetus. Effects of alcohol have been demonstrated using various MRI imaging techniques.

Researchers believe that alcohol consumed by pregnant women leads to changes in brain structure and metabolism of the fetus. These changes, which are called fetal alcohol syndrome, are reflected in the behavior and physical development of the child. According to the Centers for Disease Control and Prevention, the syndrome has an incidence between 0.2 and 1.5/1000  newborns, but the estimated annual costs of fetal alcohol syndrome child care in the U.S. is approximately $ 4 billion. Progress that has been made recently regarding MRI (magnetic resonance imaging) have made possible the discovery of changes that occur in the brain.



A study conducted by researchers in Poland on a group of 230 infants revealed interesting findings. Of the 230 infants, 200 were exposed to alcohol during pregnancy, and 30 were healthy infants (control group). To assess the effects of alcohol on the nervous system, the researchers used three different MRI techniques. Imaging techniques have been used to find the size or shape of the corpus callosum, which is a nerve structure that connects the two cerebral hemispheres.There was a significant decrease in the size of corpus callosum in infants with fetal alcohol syndrome compared with healthy babies. The researchers came to the conclusion that prenatal exposure to alcohol is one of main causes of development or absence of corpus callosum.

Andrzej Urbanik, MD, chair of the Department of Radiology at Jagiellonian University in Krakow, Poland, said that the decrease of corpus callosum has consequences on the psyche of children. Besides investigating the corpus callosum, researchers have analyzed six areas of the central nervous system with diffusion weighted imaging (DWI). This technique is based on the diffusion of water, and it seems that the accuracy of this technique is superior to MRI for detecting changes in nervous tissue structures. It was observed that babies with fetal alcohol syndrome shows increases in diffusion on DWI than healthy babies.

It should be noted that these differences are statistically significant between the two groups. Dr. Urbanik wanted to clarify that these changes suggest neurological and brain tissue damage.
Another technique used to investigate the effects of alcohol on infant was proton (hydrogen) magnetic resonance spectroscopy (HMRS).  This imaging technique also showed metabolic changes in specific regions of the brain.


Top 5 Free Medical Apps For The iPad Mini

As a technology enthusiast and medical professional that spends most of his time either holding a gadget in his hand or caring for patients I have witnessed first hand the major role that nowadays the iPad has in current medical practice. If we give it a little thought we may discover that not the iPad itself transformed the way physicians access medical information but in fact, the Medical Section in the App Store.

As you well know,  last month Apple revealed the new member of the iPad family – the iPad Mini. In this article I will focus on the iPad mini mainly due to its smaller size and therefore greater portability. The compact size and beautiful display of the iPad mini will probably make it the number one choice for any physician with a full white coat pocket. If you are not sure what to buy and you are considering buying an Android powered device and you are wondering which one is better from technical point of view, the iPad Mini or Google Nexus 7, you asked a wrong question. The quality of the medical applications is the main factor that contributes to better informed physicians and therefore superior patient caring and this is why medical professionals prefer an iPad Mini rather than a Google nexus 7.



Classification methods

  • The Doctor Tipster team analyzed more than 500 medical apps that are available for free in the iTunes store. The applications that got selected were then analyzed based on their medical usability.
  • A number of 50 physicians and medical professionals were interviewed regarding their medical app choices.

What we excluded from our list

  • iPad Mini apps that are free but require purchases afterwards.
  • iPad Mini apps that were Lite versions.
  • iPad Mini apps that need a subscription for using.

Top 5 Free Medical Apps for the iPad Mini


There is no question about it, Medscape is the number one free medical app for the iPad Mini. If you don’t believe us, you can ask the 500.000 people who already downloaded Medscape using the App Store, and there is a reason for that!

The Drug reference section of the Medscape app is one of the best of its kind, and many users have reported replacing their former drug reference apps like Epocrates with Medscape.  The drug reference section can also be used to check for drug interactions, read news and continuing medical education. As a bonus,  herbal drugs are also included.

The main difference between other iPad Mini medical apps, that are just somehow improved versions of their iPhone counterparts and Medscape – it directly targets iPad users and adapts to their needs.

The availability to access the contents of Medscape without using a network is another huge plus. This feature proves very useful when physicians don’t have a 3G network or Wi-Fi connection to rely on.

2. MicroMedex

MicroMedex for the iPad Mini despite its huge usability in the current practice, it is one of the most under rated apps of its kind. And sincerely, we do not understand why. The MicroMedex app is a great aid tool for prescribing drugs, you do not have to register, the interface is fast and responsive, very well designed and user friendly. It is becoming more and more popular among pharmacists ( is it because the app is somehow overwhelming you with toxicology and clinical teaching sections? )

3. Calculate by QxMD

Whether you’re anesthesiologist or pediatrician you must agree that a powerful medical calculator is a must have on your iPad mini. Are you nephrologist? Calculate by QxMd has this covered and offers medical care providers the feature of searching calculators for each specialty!

4. Draw MD series / Cancer.net / inMotion 3D

The use of the iPad mini in clinical practice can be also considered a powerful tool that can help physician communicate with patients and make them better understand their disease. As the years have gone by, more and more medical apps that aim to help improving the communication between physicians and patients surface. The most  representative example in this case would be the Draw MD series. These applications do exactly what you read they do. They aid doctors drawing different kinds of procedures and surgical interventions. I am sure once you give it a try and install the draw MD series on your iPad Mini, you will ditch your colored pencils that always needed sharpening.

5. Radiology 2.0: One Night in the ED

When we showed this app installed on a iPad Mini to different MDs , the first reaction we got was “it must cost a  small fortune”. I always liked the look on their faces when we told them it is actually free of charge. The reason behind this first impression is the huge amount of info stuffed in this amazing app. It contains 65 Radiology clinical cases that refer to E.M. The good part is the info can be used virtually for any other specialty not just Emergency Medicine.


New Study Reveals the Brain Differences Between Republicans and Democrats

According to a new study led by a research team from the University of South Carolina, in the United States, electing a specific candidate for the presidential elections could be related more to our biological design, rather than the analysis of the situation. Researchers suggest that there are differences between the wiring of a self-identified Republican, compared to a self-identified Democrat. This leads to a difference in values and perception between the two groups. The current study brings new data in the political neuroscience medical field. The MRIs (Magnetic Resonance Imaging) of 24 subjects were analyzed by the team.

The lead author of the study, professor Roger Newman-Norlund says that the results of the study show that the differences between the two groups are both real and significant. The subjects were asked to state their political affiliation. Afterwards, they received multiple questionnaires designed to evaluate each subjects attitude towards specific political problems. Further, an MRI was performed on each subject, assessing the connection strength between the neurons of both brain hemispheres. The frontal, supramarginal and angular gyrus were studied.

Republican Democrat

Republican Democrat

According to the research team, the results of the study indicate that Democrats are more likely to have a higher neural activity in the regions of the brain that are linked to a broader social connection, such as friends and the world. On the other hand, a higher neural activity in the brains of the Republicans was discovered in areas linked to a less-broader social connection, such as family and the country. The results of the study confirm the stereotype about Democrats and Republicans. According to this stereotype, Republicans tend to be more country-oriented whilst Democrats tend to have a global view.

“This shows the picture is more complicated. One possible explanation for our results is that Democrats and Republicans process social connectedness in a fundamentally different manner”, noted professor Newman-Norlund.

Researchers suggest that even though the political neuroscience domain is still relatively new, its future implications are big. For future political debates, campaign analysts and strategists could learn new methods that would allow them to exploit and influence the voters based on their brain differences.

Professor Newman-Norlund suggests that the brain is a combination of genetics and personal experiences. “It takes a lot of effort to see the other side and we’re not going to wake up one day and all start getting along”, he added, whilst concluding that the understanding of the existing differences is a step forward in the right direction.


Male Contraceptive Pill One Step Closer – New Method to Stop Sperm from Reaching The Ovule Discovered

A new study published in the journal PLoS Genetics reveals the possibility to stop sperm from swimming, thus setting the base for further research on the first male contraceptive pill. Researchers discovered a method to inhibit the energy supply that allows sperm to swim, thus being able to stop sperm from reaching its destination. Researchers from the Monash University in Melbourne, Australia suggest their current study could also suggest probable causes of male infertility.

The research team used laboratory mice for their tests. A mutation in the gene called RABL2 was used in the study. This gene was proven to be related to the protein fuel deliverance to the axial filament (the sperm’s tail). After inducing the mutation, researchers discovered that not only was the axial filament 17% shorter, but the sperm production also went down by almost 50%.



Professor Moira O’Bryan, the lead author of the paper, suggests that a viable pill for male contraception would be able to inhibit the action of the RABL2 gene, rather than changing it permanently. The results of the study showed that all the mice who had the mutated gene had inert sperm and were also proven to be infertile. However, according to professor O’Bryan, their behavior was not affected.

She notes that “The challenge with developing the male pill isn’t rendering the sperm infertile, but turning them back on again”. Researchers found that the gene is not only located in the testicles, but also in the brain, the kidneys and the liver. Researchers from the Cambridge and Newcastle Universities were also involved in the study.

According to precedent studies, almost 55% of the patients questioned are willing to try the male contraceptive pill. However, a recent study from the United Kingdom, published in 2010, reveals that women don’t trust that men would take the pill on a daily basis. There are currently other forms of male contraception, which includes a monthly injection. It’s based on testosterone and the result is the regulation of two brain chemicals that temporarily block sperm production.

According to a clinical trial conducted in China, which involved 1,000 male patients, over a period of two years, these injections were proven to have an efficiency of preventing pregnancy of almost 95%. However, 30% of the patients stopped participating in the clinical trial due to side effects which included acne, mood swings and a lower sex drive.

An interesting alternative comes from a research that has been presented in Houston, 3 moths ago at the annual meeting of the Endocrine Society. Scientists then managed to create a contraceptive gel  called Nestorone (a combination of synthetic progestin and testosterone).

Another viable option for male contraceptives is a pill that blocks sperm from being released during ejaculation. This pill uses a combination of chemicals that are also found in anti-psychotic and blood pressure medication used almost 4 decades ago. These chemicals paralyze specific muscles found in the male reproductive system, thus blocking semen. Studies have revealed that these pills have no side effects or adverse effects on sexual performance or libido. According to researchers from the King’s College Hospital from London, the pill can be used anytime because it takes 3 hours to reach the desired effect, which lasts for approximately 48 hours.


Investigating new drug for Chron’s disease

Researchers are investigating a new drug to treat Crohn’s disease. Ustekinumab, a monoclonal antibody, is an immunosuppressant that had positive results in studies performed so far by researchers at the University of California at San Diego, School of Medicine. The study was published in The New England Journal of Medicine.

IBD (Crohn’s disease and ulcerative colitis) are chronic inflammatory diseases of the gastrointestinal tract that is manifested by abdominal pain, diarrhea, intestinal bleeding, weight loss, loss of appetite, fever etc. There may be extra-intestinal manifestations such as uveitis, arthralgia, erythema nodosum, etc.. Symptoms affect patients throughout life with periods of remission and periods of attack. The difference between these two diseases is made by intestinal mucosa biopsy and histopathology. Crohn’s disease is affecting discontinuously the intestinal  mucosa with segments of normal mucosa (transmural lesions) between lesions (cobblesstone) while ulcerative colitis is characterized by lesions strictly limited to the mucosa.

drug for Chron's diseaseIt should be noted that medical treatment of these diseases differs according to the stage of disease. Surgery is indicated especially when complications arise: fistulas, fissures, obstruction. Medical treatment includes salicylic acid derivatives (5 aminosalicylic), corticosteroids, immunomodulators (methotrexate, azathioprine, cyclosporine), biological agents (infliximab), antibiotics etc. Besides being a chronic disease that affects the quality of life of patients, Crohn’s disease is not always easy to treat. There are patients who do not respond or respond well to treatment initially and then have to change treatment because it is not effective.
Now researchers at the University of California at San Diego, School of Medicine investigate a new drug to control symptoms of Crohn’s disease. So far the results show that Ustekinumab increased clinical response and remission in patients with moderate to severe Crohn’s disease. Sanborn, MD, principal investigator and chief of the Division of Gastroenterology at the UC San Diego School of Medicine, said that it is a big challenge to treat patients who are resistant to inhibitors of TNF (tumor necrosis factor) such as Humira, Remicade etc.
The researchers made a randomized placebo-controlled that included five hundred and twenty-six patients from 12 countries. Study duration was 36 weeks and clinical outcomes were observed after 6 weeks. Now this drug will be tested in a phase 3 clinical trial to confirm the results. It should be noted however that Ustekinumab has significant side effects. As an immunosuppressant, this drug can give severe infections and even certain cancers. 5 patients included in the study had severe infections and one developed basal cell carcinoma.
Ustekinumab is an immunosuppressant that blocks inflammation by inhibiting two proteins (IL 12 and IL 23). Ustekinumab has been approved by the FDA for the treatment of psoriasis.


Weight-Loss Surgery Ineffective Against Obstructive Sleep Apnea

A recent study shows that even though the effectiveness of bariatric surgery (also known as weight-loss surgery) has been shown, the effect of the procedure on OSA (Obstructive Sleep Apnea) is negligible. A research team from the Alfred Hospital, the Baker IDI Heart and Diabetes Institute and the Alfred Hospital, in Australia, compared the effect of surgical intervention and medically supervised weight loss programs on OSA. The paper, published in the Journal of the American Medical Association, shows the results of the worlds first high-quality randomized trial conducted on severely obese individuals.

Obstructive Sleep Apnea is an illness that affects almost 5% of the population of Australia. The main event of this disorder consists in several abnormal breathing pauses that occur during a sleep cycle. These pauses can last from a few seconds to a few minutes and can be diagnosed through the use of a method called polysomnography. One of the causes of OSA is the obstruction of the upper airways caused by the accumulation of body fat around the neck level.


Against Obstructive Sleep Apnea

 The leading authors of the study are associate professor John Dixon, from the Monash University and professor and sleep specialist Matthew Naughton from the Monash and Alfred Hospital. The selection criteria for the trialled subjects were an earlier diagnose of moderate or sever Obstructive Sleep Apnea and a BMI (Body Mass Index) ranging between 35 and 55. These patients were divided into two groups, each following either the surgical or the conventional weight loss method, and were followed for two years, on a monthly basis.

Results showed that the group of patients who underwent LAGB (Laparoscopic Adjustable Gastric Banding) managed to lose almost 20% of their initial weight, on average. The group of patients who participated in a conventional weight loss program only lost 3% of their initial weight. Dixon said that this impressive difference in weight loss does not have an effect of OSA. Improvements in OSA were monitored through the use of polysomnography.

“Both groups experienced a reduction in OSA severity, but the difference between the surgical group and the conventional group was surprisingly small”, said professor Dixon. He added that most of the patients from both groups still required a CPAP (Continuous Positive Airway Pressure) machine.

The research team concluded that even though weight loss is directly associated with the reduction of Obstructive Sleep Apnea, the effects vary from one individual to another. According to the research team, the best improvement shown in OSA was associated with a light weight loss, instead of an excessive weight loss.


Researchers Develop New Molecule Capable of Carrying Drugs in the Body

A research team from the Kansas State University, in the United States of America, has discovered a new molecule that could be capable of delivering medication inside the organism in order to treat various illnesses.

This is the first time that a research team manages to design and create a membrane-bounded vesicle that is completely made out of peptides. Peptides are small molecules consisting of amino acids. Scientists say that their new molecule will be capable to deliver drugs into the organism, targeting tumors and neurodegenerative diseases.

The study, led by biochemistry professor John Tomich was recently published in the journal PLOS ONE. A patent for the molecule is currently pending. Professor Tomich describes these new molecules as žbubblesť, because of the chemical properties of the peptides. These peptides consist of naturally occurring amino acids, that form a shape that is hollow on the inside. When created in a solution containing water, the bubble is filled with water instead of being filled with air.

The newly developed molecules can be created in a solution that contains a certain drug, thus allowing the drug to be encapsulated in the bubble. This resembles a gelatin capsule that usually contains oral medication. These vesicles can then be administered in the particular part of the organism, thus minimizing any potential adverse effects.

“We see this as a new way to deliver any kind of molecule to cells. We know that in certain diseases subpopulations of cells have gone awry, and we’d like to be able to specifically target them instead of attacking every cell, including healthy ones”, said professor Tomich.

Artificial Vesicle

Artificial Vesicle

 Another use of the new molecule could be in gene therapy. Gene therapy is currently undergoing numerous clinical trials, having one major challenge: the delivery of the genes to the correct location. Current methods include the injection of cells that contain a virus into the organism, to be further carries by liposome-fatty compounds. However, this current method has several side effects. One of these side-effects is that if a virus is used, the immune system of the patient could attack it or even cause a tumor. Furthermore, the lipid-based carry system could cause local inflammation that would lead to an improper cellular binding.

The newly developed molecules have a major advantage over the current systems. The peptides that are being used to create the vesicle have an improved durability and stability. Moreover, they are created faster, are easier to use and they can be injected into a specific area of the body.

Professor Tomich said that these peptides have the ability to target organs, tumors, tissues or even cells, whilst also being able to encapsulate antibodies, toxins and other chemical reagents. He concluded that the current discovery has a potential that is still waiting to be discovered.


Researchers Discover Path To Erase Fear From the Brain

A new study conducted by the researchers from the Uppsala University, in Sweden, reveals that there is a way to erase newly formed emotional memories. This is a breakthrough finding in the research field of memory and fear.

The lead author of the study, Thomas Ă…gren,  has managed to show that these newly formed emotional memories can be completely erased from the human brain. Ă…gren was supervised by Tomas Furmark and Mats Fredrikson, both professors at the Uppsala University.

Long term memory is based on the formation of several proteins. These proteins are part of the consolidation process that occurs when a person learns something new. Remembering something causes the memory to become unstable for short amount of time, only to recover through another consolidation process. The explanation is that when the remembering process occurs, the person doesn’t actually remember what initially happened. Instead, it remembers the last time he or she thought about that particular memory. Through the disruption of the consolidation process, the content of the memory can be affected.

child fear


 In the study conducted by the researchers from the Uppsala University, a neutral image was shown to the tested subjects. simultaneously, researchers administered an electric shock. Through this process, the shown image managed to cause fear, thus creating a fear memory for the subjects. Furthermore, researchers showed the picture again, in order to activate this recently formed fear memory, without applying the precedent electric shock. Researchers divided the subjects into two groups. The consolidation process of the first group was disrupted through multiple presentations of the picture, whilst the consolidation process of the second group wasn’t interrupted, although after the process was complete, the picture was shown to the group.

Researchers discovered that the group that had their consolidation process inhibited, the fear that was previously associated with the picture had dissipated. What researchers have shown is that if the consolidation process is interrupted, the memory no longer incites fear. Simultaneously, an MR-scanner was used to show that the remains of that particular fear memory had also been erased from the nuclear group of the amygdala. This nuclear group is responsible for the storage of fear memories and is found in the temporal lobe.

“These findings may be a breakthrough in research on memory and fear. Ultimately the new findings may lead to improved treatment methods for the millions of people in the world who suffer from anxiety issues like phobias, post-traumatic stress, and panic attacks”, said Thomas Ă…gren.

To view the study abstract please click here.


Linzess New Drug For Irritable Bowel Syndrome And Chronic Constipation Treatment Approved By FDA

FDA approved Linaclotide (Linzess),  a peptide agonist of guanylate cyclase 2C as one-daily treatment for adults with chronic idiopathic constipation and irritable bowel syndrome.

Researchers assessed linaclotide for both the treatment of irritable bowel syndrome and chronic idiopathic constipation  treatment. In order to establish the safety and effectiveness of Linzess, researchers conducted 2 double-blind studies (in which both the participants and researchers are unaware of whether the participant is receiving the drug or a placebo) for management of irritable bowel syndrome and chronic idiopathic constipation. In the first clinical trial were included 1604 patients, randomized to receive either linaclotide or placebo for a period of 12 weeks. Study results showed that patients who received linaclotide had fewer abdominal pain. In the second clinical trial were included 1272 patients that were randomly assigned to take Linzess at doses of 145 mcg or 290 mcg or a placebo for a period of 12 weeks. The results of this study showed that linaclotide in doses of 145 mcg was more effective than doses of 290 mcg or placebo for the treatment of chronic idiopathic constipation.

Dyspepsia (or functional gastrointestinal disease) refers to upper abdominal pain, heartburn, nausea, vomiting or discomfort that lasts for more than 3 months. Rome Consensus classified this disease into several categories: functional esophageal disorders, peptic functional disorders, functional bowel syndrome, functional anorectal disorders and abdominal pain due to functional cause.

Irritable Bowel Syndrome

Irritable Bowel Syndrome

Functional gastrointestinal disease is manifested by pain or other gastrointestinal symptoms with no apparent cause (paraclinical explorations can not reveal the presence of organic lesions). Therefore, the diagnosis of functional disease is one of exclusion that is established after the patient was investigated for other gastrointestinal disorders. Pathogenesis of these diseases remains unclear although several theories have been proposed. There seems to be a genetic predisposition that causes functional diseases such as irritable bowel syndrome. It is believed that environmental factors, emotions and stress are involved in the pathogenesis of this diseases. There seems to be a change in the threshold of pain perception in patients with irritable bowel and abdominal pain due to functional cause. Motility disorders, disorders of vagal nerves regulation are other mechanisms proposed to explain functional bowel diseases. Functional gastrointestinal diseases, such as irritable bowel syndrome are difficult to treat because there is no known cause that underpin these symptoms.

Irritable bowel syndrome is characterized by chronic abdominal pain, discomfort, bloating and disturbed defecation. In irritable bowel syndrome may predominate constipation or diarrhea. Although there is no cure for this disease, many treatments have been proposed. The treatment of irritable bowel syndrome is generally difficult and the results are often not the expected. Being a functional pathology, the mental component is important, so the role of psychological balancing is also important. Diet may helpful in cases were constipation is the predominant symptom and should include foods that are tolerated by patient and with an increased fiber content.

Drugs such as antacids and gastric secretion inhibitors may be helpful in the treatment of irritable bowel syndrome. Histamine receptor antagonists (ranitidine, famotidine) or proton pump inhibitors (omeprazole) reduce gastric acidity and can relieve heartburn.

Prokinetics (metoclopramide, domperidone) are useful in digestive motility disorders. Prokinetics stimulate gastrointestinal motility which eases pain from chronic constipation. Laxatives and antidiarrheal can be used in cases of irritable bowel syndrome were constipation or diarrhea are the predominate symptom.


Food and Drug Association Approved Enzalutamide For Treating Prostate Cancer

Food and Drug Association approved a new treatment for metastatic prostate cancer. Enzalutamide (Xtandi) is an androgen inhibitor that has been shown to increase survival rates of patients with prostate cancer. Because the results of  previous clinical trials were promising, the researchers assessed the efficacy and safety of enzalutamide for the treatment of prostate cancer. The study was conducted on a sample of 1199 patients who were randomly divided to receive either enzalutamide or placebo. Study results showed that patients treated with enzalutamide had an overall  survival of 18.4 months, unlike the others who had an overall survival of 13.6 months. The study included patients with castration-resistant prostate cancer who were previously treated with docetaxel.

Enzalutamide Logo

Enzalutamide Logo

Patients who had stroke, seizures, brain metastasis, were excluded from the study. Enzalutamide has some precautions. One of these precautions is the risk of seizures. 0.9% of patients who had received enzalutamide experienced a seizure. In all patients in whom these side effects occurred the treatment was discontinued. Other adverse events reported were fatigue, back pain, joint pain, headache, dizziness, muscle weakness, and others.

Prostate cancer is the most common form of cancer in men and the second leading cause of death from cancer after lung cancer. The risk of developing prostate cancer increases with age, but there are other factors incriminated in the occurrence of this cancer. Hormonal factors, hereditary factors and environmental factors seem to be involved in prostate cancer development. Also, it seems that this cancer is more common in Afro-American men. Sexually transmitted infections are also a risk factor for prostate cancer. Men who had sexually transmitted infections are 1.4 times higher risk of prostate cancer. Other factors include obesity and smoking. The only way to prevent prostate cancer is early detection. Although controversial, some recommend screening for prostate cancer in all men after age 40. Screening for prostate cancer consists of rectal examination and PSA (prostate specific antigen) measurement.

Hormonal factors seem to play a role in prostate cancer. It seems that testosterone, the male hormone, helps growth and proliferation of tumor cells. Testosterone is produced by the testes under the influence of LH-RH (luteinizing hormone-releasing hormone). Consequently, scientists have thought that the testosterone receptors are a good target for cancer therapy. In other words, it is a castration because the action of testosterone in the body is blocked. Many treatments have been tried to block androgen signaling pathway, but there are tumors that become resistant to hormone therapy. Therefore, approval of a new dug to prolong survival is a new hope for patients with metastatic prostate cancer.