The study examined changes in and relationship between body mass index (BMI), leptin and adiponectin levels over a 3-year period in a pediatric population-based cohort.A 3-year prospective cohort study of 268 boys and 251 girls aged 9–10 in Ina, Saitama, Japan.2 (P < 0.001) and in girls from 16.5 to 18.5 kg/m2 (P < 0.001), respectively. Adiponectin values significantly decreased from baseline to follow up in boys  (P < 0.001) and in girls  (P < 0.001). Leptin values at follow up significantly decreased from baseline in boys  (P < 0.001) and also in girls  (P = 0.049).Median body mass index (BMI) significantly increased from baseline (age 9–10) to follow up (age 12–13) in boys from 17.1 to 18.3 kg/mr = 0.864, P < 0.001 in boys; r = 0.873, P < 0.001 in girls), adiponectin , and leptin  before and after the three-year period.A relatively strong correlation was seen in BMI  and positively correlated with that for leptin .The ratio of follow up to baseline BMI was negatively correlated with that for adiponectin (This study demonstrated that baseline adiponectin, leptin and BMI values measured at ages 9–10 correlated with those measured three years later. However, adiponectin values decreased and leptin values increased in those subjects whose BMI increased during over this period. The prevalence of pediatric obesity is rising sharply throughout the world, with marked increases also seen in Asia, including Japan -3. WhileWhitaker RC et al.  reportedIn our study, we focused on the 3-year-period corresponding to the ages during which the onset of obesity is most likely to lead to either adult obesity or CAD ,7,10. WiThis study was conducted as part of a pediatric health promotion program -14 initiThe subjects of this study were children aged 9–10 who, in September 1999 or 2000, were all in the fourth grade in 3 elementary schools in town, and who agreed to participate in the study. A total of 304 boys and 282 girls took part in the study's initial survey (100% registration rate). A follow-up survey was conducted when the subjects reached the seventh grade (ages 12–13).At the time of the initial and follow-up surveys, the subjects underwent blood tests including leptin and adiponectin measurements and physical measurements that included height and weight.Adiponectin was measured in accordance with a report by Arita et al using commercially available ELISA kits  with intra- and inter-assay coefficients of variation below 10% . Leptin All values were expressed as median and interquartile range (IQR). The Kruskal-Wallis test was used to evaluate statistical significance.Baseline values for each of the variables examined  were recorded when the subjects were 9–10 years old. These values were again measured three years later when the children were aged 12–13  at Jikei University School of Medicine and Showa University School of Medicine. Written informed consent was obtained from all study participants and their guardians.P = 0.512) and BMI (P = 0.958).Of the 586 children, follow-up physical and laboratory examination was performed on 519 subjects three years later . Relocation was the major reasons that children were lost to follow-up. There was no statistical difference in baseline values between those available for follow-up and those lost to follow-up in gender (2) for boys was 17.1 (15.7–18.7) increasing to 18.3 (16.9–19.8) at follow up (P < 0.001), and 16.5 (15.2–18.3) increasing to 18.5 (17.0–20.3) in girls (P < 0.001) respectively. The mean baseline adiponectin value (μg/ml) in boys dropped from 13.5 (9.6–18.2) to 8.9 (6.9–11.3) at follow up (P < 0.001), and dropped from 12.4 (9.5–16.5) to 9.5 (7.4–11.8) in girls (P < 0.001) respectively. The mean baseline leptin value (ng/dl) dropped from 4.9 (3.2–7.8) to 2.3 (1.6–3.6) in boys (P < 0.001) compared to a respective drop from 5.3 (3.8–9.2) to 5.1 (3.6–7.9) in girls (P = 0.049).Body mass index (BMI) was significantly increased and adiponectin and leptin significantly decreased among study participants for both genders before and after the three-year follow-up. The mean baseline BMI value ; adiponectin , and leptin  . In contrast a positively correlation was reported for the follow up to baseline leptin ratio with that for BMI in both sexes   correlated with those measured three years later. Therefore, these three variables measured at ages 9–10 were predictive for results obtained three years later, suggesting that in this age group these variables were likely to be genetically determined. However, adiponectin values were relatively decreased and leptin values relatively increased in children whose BMI increased during the 3-year period. Of note, Cambuli VM et al. reported that adiponectin and leptin were positive metabolic outcome markers following lifestyle intervention in overweight and obese children .The current study showed that adiponectin values measured at ages 12–13 were lower than at ages 9–10. Similar findings have been reported in Germany and in USA, showing that adiponectin values in post-pubertal children are lower than in pre-pubertal children, especially in boys, which is explained by the elevated serum androgen levels in the former ,21. OtheThis study also demonstrated that the leptin values at ages 12–13 were lower than those at ages 9–10, especially in boys. Leptin values, which correlate with the amount of body fat present, are reported to increase in girls and decrease in boys after Tanner stage 2 as the pubertal developments proceeds . AnotherThe current study examined changes in BMI and adipocytokines in Japanese children. Differences in adipocytokines between ethnic groups have been demonstrated in previous reports in the literature ,27. TherLimitations of this study include the lack of confirmation of pubertal stage (Tanner's stages) of all subjects, as this would have been useful to correlate with the data obtained; this was an observational study covering a specific 3-year period and therefore the values obtained for the metabolic markers may not necessarily be linked directly to adult obesity. This study examined the relationship between the changes in test variables and obesity, and did not take the subjects' lifestyles into consideration. Therefore, evaluation of lifestyle factors is an issue that needs to be addressed in the future.In conclusion we demonstrated in a Japanese population-based childhood cohort that baseline adiponectin, leptin and BMI values measured at ages 9–10 correlated with those measured three years later. In addition, those children with an increase in BMI over this period were also found to have decreased adiponectin and increased leptin values. These results suggest that lifestyle intervention in obese children should be initiated between ages 9 and 12.It is hoped that continued follow-up of the study participants will help identify potential methods of preventing the onset of visceral obesity and CAD in adulthood.The authors declare that they have no competing interests.RN and NT participated in the design of the study and performed the statistical analyses. HS, TM, AM, YM, TS, and AK participated in the coordination of the study. RN helped to draft the manuscript. All authors have read and approved the final manuscript.


To evaluate the effect of intravitreal bevacizumab (avastin) injection in cases of neovascular glaucoma.Clinical case series.Sixteen eyes of 16 patients with rubeosis iridis and secondary glaucoma were administered intravitreal injection of bevacizumab (2.5 mg). The patients were followed for 2 months.We noted partial or complete regression of iris neovascularization 1 week after injection of bevacizumab. Reproliferation of new vessels was detected in 25% of the cases after 2 months. The mean intraocular pressure (IOP) before injection was 28± 9.3 mm Hg under topical ß-blocker and systemic acetazolamide. One week after injection, the IOP decreased to 21.7± 11.5 mm Hg .Intravitreal bevacizumab (avastin) injection leads to regression of iris neovascularization with subsequent drop of IOP in eyes with neovascular glaucoma. Neovascular glaucoma is a serious disorder, which occurs as a late complication of ischemic retinopathies. It is now well known that vascular endothelial growth factor (VEGF) plays a principal role in ocular conditions characterized by neovascularization.4This is a prospective, observational clinical case series.Sixteen eyes of 16 patients with rubeosis iridis and secondary glaucoma were included in this study. The primary cause for iris neovascularization was proliferative diabetic retinopathy (PDR).Eight eyes had been previously treated with laser photocoagulation for their ischemic retina before inclusion in the study. Ocular examination included visual acuity assessment, slit-lamp biomicroscopy of the anterior segment, gonioscopy, applanation tonometry, indirect ophthalmoscopy and finally fluorescein angiography of iris neovascularization. The iris neovascularization was graded according to the iris angiography grading system.6All patients received intravitreal injection of bevacizumab (avastin), 2.5 mg in 0.1 mL. The following steps were used for injection: Eye speculum application, disinfection of conjunctival sac with povidone iodine 5% and then the intravitreal injection through lower outer quadrant 3.5-4 mm posterior to the limbus. Retinal photocoagulation was applied for cases with clear media as soon as possible after intravitreal injection. Cyclodestructive procedure cryotherapy application or glaucoma surgery (glaucoma drainage device implantation) was performed for eyes in which intraocular pressure (IOP) reduction was inadequate.nd postoperative day; and then at 1st, 4th, 6th and 8th weeks postoperatively.The patients were followed daily for 1 week and then weekly, for 2 months. Fluorescein angiography for iris neovascularization was done for every patient on the 2The study was approved by the local ethics committee, and all patients signed informed consent before entering the study. All applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research.This study included 16 patients ; their ages ranged from 46 to 67 years . The right eye was affected in 9 cases; and the left, in 7 cases. As shown in After intravitreal injection of bevacizumab, the iris angiogram showed regression  of the new vessels with decreased vascular permeability in all cases (100%) within 1 week . After 2Examination of the angle of the anterior chamber revealed complete regression of new vessels of the angle in all cases within 1 week. Peripheral anterior synechiae (PAS) remained unchanged during follow-up period except in 1 case (case 10), which showed more synechial angle closure together with reproliferation of new vessels in the angle and subsequent re-elevation of IOP.th and 8th weeks, respectively.One week after bevacizumab injection, the IOP decreased in 14 (87.5%) cases, while it remained persistently high in 2 (12.5%) cases (cases 1 and 9). These 2 patients underwent cyclodestructive procedure. (Cyclocryo procedure was done once in case no. 1 and twice in case no. 9.) The IOP decreased to below 20 mm Hg without the need of topical or systemic treatment in 5 (31.25%) eyes; while 6 (37.5%) eyes required topical β-blocker, and 1 (6.25%) eye was treated with topical β-blocker and systemic acetazolamide. In 2 (12.5%) cases (cases 4 and 14), though IOP decreased, it still remained above 20 mm Hg, and glaucoma valve implantation was done for each. Follow-up of the 12 cases with controlled IOP (< 20 mm Hg) for 2 months showed nearly stable IOP except in 2 cases (nos. 10 and 15), where the IOP re-elevated in the 7The mean IOP before injection was 28± 9.3 mm Hg under topical β-blocker and systemic acetazolamide. One week after injection, the mean IOP decreased to 21.7± 11.5 mm Hg . Two months after bevacizumab injection, the mean IOP was 16.7± 4.1 mm Hg. At the end of follow-up, the visual acuity improved in 9 (56.25%) cases (56.25%), worsened in 1 (6.25%) case and remained at the same level in 6 (37.5%) cases. Improvement was mainly due to clearing of ocular media. Vitreous hemorrhage improved in 4 cases, and hyphema disappeared in 1 case. Only 1 case with significant vitreous hemorrhage (case no. 2) resisted clearance within the follow-up period. The effect of the drug on the macular area was not studied.Clearance of ocular media together with improvement in pain and discomfort after intraocular injection allowed application of laser to the ischemic retina. Laser application was feasible in all except 3 cases .et al.In 2006, Kahook nd day post-treatment. This is consistent with the results of the studies by Oshima et al.et al.In this case series, the effect of intravitreal bevacizumab (2.5 mg) injection on 16 eyes with iris neovascularization and secondary glaucoma was studied. Angiography of iris neovascularization revealed regression  in all cases 100%), which started from the 20%, whichet al.et al.In our study, complete regression of iris neovascularization occurred in 37.5% of eyes within 2 months, while Oshima et al.In this study, reproliferation of iris neovascularization was detected in 4 (25%) cases at 6 weeks after the intravitreal injection. Oshima et al.Iliev et al.After intravitreal bevacizumab injection, the visual acuity improved in 9 (56.25%) cases, which was due to clearing of corneal edema, hyphema and/or vitreous hemorrhage. Rapid improvement of vitreous hemorrhage after intravitreal bevacizumab injection was observed in another study.The current study demonstrates that intravitreal bevacizumab injection can successfully produce regression of iris neovascularization with subsequent decrease in IOP in cases of neovascular glaucoma.Bevacizumab as a pharmacological treatment has the advantage of being rapid in effect but has the disadvantage of limited duration of action. Combining intravitreal bevacizumab injection with panretinal photocoagulation can offer both rapid and long-lasting effect.Another advantage of bevacizumab is the ability to use this modality to treat eyes with opaque media which preclude treatment with laser photocoagulation.Lastly, this study demonstrates that intravitreal bevacizumab injection may be the first choice, but not the only option in the treatment of neovascular glaucoma.


To analyse coverage of childhood vaccinations in a rural South African population and investigate whether maternal HIV status is associated with children’s vaccination status.2 431 children with complete information, 12–23 months of age at some point during the period January 2005 through December 2006 and resident in the Africa Centre Demographic Surveillance Area at the time of their birth were investigated. We examined the relationship between maternal HIV status and child vaccination status for five vaccinations  in multiple logistic regressions, controlling for household wealth, maternal age, maternal education and distances to roads, fixed and mobile clinics.P≤ 0.036] except measles , distance to mobile clinic was negatively associated with vaccination status , household wealth was positively  and distance to nearest road negatively  associated with vaccination status.Coverage of the five vaccinations ranged from 89.3% (95% CI 81.7–93.9) for BCG to 77.3% (67.1–83.6) for measles. Multivariably, maternal HIV-positive status was significantly associated with lower adjusted odds ratios (AOR) of child vaccination for all vaccines [(AOR) 0.60–0.74, all Positive maternal HIV status independently reduces children’s probability to receive child vaccinations, which likely contributes to the morbidity and mortality differential between children of HIV-positive and HIV-negative mothers. As a means of increasing vaccination coverage, policy makers should consider increasing the number of mobile clinics in this and similar communities in rural Africa. Child vaccinations are among the most cost-effective public health interventions . GloballFactors that are determinants of childhood vaccination are maternal age , distancThe relationship between a mother’s HIV status and vaccination status of her children will be especially important for population child health in countries with high HIV prevalence, such as South Africa  or they We use data from a large demographic surveillance in rural KwaZulu-Natal, South Africa to analyse coverage of childhood vaccinations and to investigate the relationship between maternal HIV status and child vaccination status.2 and a total population of 87 000 (The Africa Centre Demographic Surveillance Area (DSA), in Umkhanyakude district of northern KwaZulu-Natal, South Africa, covers 438 kmf 87 000  in 11 00f 87 000 . The areThe community has high HIV prevalence, approximating 40% in women attending antenatal clinics  at the time of birth of the child.Trained interviewers visited households and administered a standardised questionnaire in the local language, isiZulu  and the WHO guidelines .We used logistic regression analyses to assess associations with child vaccination status. All analyses were performed in In multivariable regressions, we included several variables whose associations with child vaccination are well documented, namely, maternal education , maternaAs mother’s HIV status, we took the result of each mother’s HIV test in the surveillance, taken closest in time to the date of birth of her child included in our sample. About half (52%) of the children sampled had mothers who had not received an HIV test within the Africa Centre HIV surveillance. To deal with this group of children missing maternal HIV, we included these children in our sample, assigning the variable “maternal HIV status” the value “unknown”. In addition, we ran separate regression analyses excluding children of mothers with missing HIV status.We measured household wealth with a household wealth index. As shown by Of the 2669 children resident in the Africa Centre DSA at birth and aged 12–23 months at the time of the interview, 151 (5.6%) had mothers who were not resident in the DSA, while for 87 (3.5%) information on distance to roads and clinics was missing. Our final sample for analysis thus included 2431 children, i.e. 91% of the total of 2669 children. A RTH card was available for 44% of the children included in our sample; for the remainder vaccination information was available from maternal recall. The median age of mothers was 24 years (IQR 13–54) with 11% HIV-positive, 37% HIV-negative and 52% of unknown HIV status .P= 0.573), household wealth index (P= 0.915), distance to the nearest mobile clinic (P= 0.949), distance to the nearest road (P= 0.964), distance to the nearest mobile clinic (P= 0.949) and distance to the nearest road (P= 0.964). Compared to mothers who consented to an HIV test within the surveillance, mothers who did not consent were from wealthier households, had higher education levels and were older , or if their mothers were not resident in the DSA at the time of their birth. None of the children were excluded for both reasons. We compared the children who were included in the analysis to the children who were excluded because of the first reason and, separately, to the children excluded because of the second reason. No significant differences were found between any of the groups in maternal HIV status  81.7–93.9) and lowest for measles vaccine . The other vaccination coverages were 87.3% for polio3 (95% CI 79.4–92.5), 84.9% for DTP3 (95% CI 76.6–90.6), and 81.7% for HepB3 (95% CI 73.0–88.1). There was marked geographic variation in DPT3 coverage ranging between 17.8% and 97.8%  .In univariable analysis, there was evidence for an association between maternal HIV status and child vaccination status. The unadjusted odds ratios (OR) of maternal HIV status on individual vaccinations were 0.62 for BCG (95% CI: 0.41–0.94), 0.73 for polio3 (0.56–0.97), 0.73 for DTP3 (0.56–0.96), 0.74 for HepB3 (0.56–0.97) and 0.78 for measles (0.57–1.06) . Living P≤ 0.029). Net of the other factors in the regression, children who live in households belonging to highest wealth tertile had significantly higher odds of having received BCG and measles vaccination than children living in poorer households  while an increase in distance to the nearest road showed evidence for an association with lower odds of receiving polio3, DTP3, and HepB3 vaccinations . All else being equal, maternal age, maternal education, and distance to fixed clinic showed no evidence for an association with child vaccination status.When controlling for household wealth, maternal age, maternal education, distance to the nearest mobile clinic, distance to the nearest fixed clinic, and distance to the nearest road in multivariable analysis, children born to HIV-positive mothers had lower adjusted odds ratio (AOR) of having received the vaccinations than children of HIV-negative mothers: 0.60 for BCG (95% CI 0.39–0.92), 0.74 for polio3 (0.55–0.97), 0.74 for DTP3 (0.55–0.98), 0.74 for HepB3 (0.56–0.98) and 0.75 for measles (0.55–1.03) . The sizThe main regression results are robust to the exclusion of individuals with mothers with unknown HIV status. None of the AOR changed by more than 5%. In particular, the AOR of maternal HIV status on individual vaccinations were 0.60 for BCG (95% CI 0.39–0.93), 0.72 for OPV3 (0.54–0.97), 0.72 for DTP3 (0.54-0.96), 0.72 for HepB3 (0.54-0.96) and 0.76 for measles (0.55–1.05). Further, the main results remained robust to the exclusion of individuals with missing data on wealth or maternal education. Particularly, the AOR of maternal HIV status on individual vaccinations were 0.54 for BCG (95% CI 0.34–0.85), 0.67 for OPV3 (0.49–0.92), 0.68 for DTP3 (0.50–0.92), 0.67 for HepB3 (0.49–0.92) and 0.71 for measles (0.51–0.99).We have shown high coverage of childhood vaccination in the Africa Centre DSA ranging from 89.3% for BCG to 77.3% for measles with marked geographic variation of DTP3 in the population (mean ranging from 17.8% to 97.8%). The children born to HIV-positive mothers in the DSA are significantly less likely to receive routine childhood vaccinations in the first year of life than children born to HIV-negative mothers, when controlling for maternal age, household wealth, and distance to mobile clinics, fixed clinics and nearest road. The lower likelihood of vaccination coverage adds to other disadvantages children of HIV-positive mothers are likely to experience  while the fixed clinics provide comprehensive primary care, of which vaccinations are only one small component. One reason why distance to the fixed clinics is not a significant predictor of vaccination status may thus be that mothers perceive mobile clinics to be the best places for their children to receive vaccinations and thus preferentially use mobile clinics for these vaccination services.In previous studies in developing countries, distance to primary health care facilities significantly predicted vaccination status . We findStudies from Africa have found a positive relationship between socio-economic status and vaccination status . This could over-estimate the true vaccination coverage. Third, we do not have information on children’s HIV status and thus cannot directly control for it in our analyses. However, a large proportion (35%) of HIV-positive children would have died before their first birthday , it falls below 60% in one third of the study area. At 77% overall measles coverage is below the level needed for herd immunity (which is estimated at 93–95%;


The radiation-induced genotoxic damage in three established cell lines and 15 primary cultures of human malignant melanoma and ovarian carcinoma showing different radiosensitivity was tested by the cytokinesis-block micronucleus assay. A dose-related increase in micronucleus frequency was observed in all the cell systems. The mean number of micronuclei per Gy of ionising radiation per binucleated cell was respectively 0.44 +/- 0.0075 and 0.43 +/- 0.04 for M14 and JR8 malignant melanoma cell lines and 0.19 +/- 0.013 for the A2780 ovarian cancer cell line. The number of micronuclei did not rank the cell lines in the same order of radiosensitivity as clonogenic cell survival, which showed a surviving fraction at 2 Gy of 0.38 +/- 0.02 for JR8, 0.34 +/- 0.05 for M14 and 0.22 +/- 0.007 for A2780. As regards primary tumour cultures, no correlation was observed between micronucleus induction and surviving fraction at 2 Gy. In conclusion, the discrepancy we observed between micronucleus formation and cell death raises doubts about the potential of the micronucleus assay as a preclinical means to predict radiosensitivity.


These parasites are an unrecognized food safety risk in a population with a tradition of eating raw fish. Clonorchis sinensis was recovered from 51.5%, but >1 of 4 intestinal species of the family Heterophyidae was recovered from 100%. The most numerous were Haplorchis spp. . These results demonstrate that fishborne intestinal parasites are an unrecognized food safety risk in a country whose people have a strong tradition of eating raw fish.Although fishborne zoonotic trematodes that infect the liver are well documented in Vietnam, intestinal fishborne zoonotic trematodes are unreported. Recent discoveries of the metacercarial stage of these flukes in wild and farmed fish prompted an assessment of their risk to a community that eats raw fish. A fecal survey of 615 persons showed a trematode egg prevalence of 64.9%. Infected persons were treated to expel liver and intestinal parasites for specific identification. The liver trematode  Clonorchis sinensis, Opisthorchis viverrini, and O. felineus cause cholangitis, pancreatitis, and cholangiocarcinoma in humans  are estimated to infect >18 million persons; worldwide the number at risk may be much greater  (4). TheC. sinensis  in humans , Hanoi, and the Faculty of Tropical Medicine, Mahidol University, Bangkok. Each study participant signed a consent form, which is on file at NIMPE.From each stool sample, 2 Kato-Katz smears were prepared and analyzed by using the standard kit provided to NIMPE by the World Health Organization and originally obtained from Vestegaard Frandsen Pvt. Ltd. . Fecal slides were examined by light microscopy (×400). Helminth eggs were identified and enumerated, and the number of eggs was multiplied by 23 to obtain the number of eggs per gram (epg) of feces.>1,000 epg on fecal examinations were selected for worm expulsion. Selected patients were asked to eat a light liquid dinner the evening before treatment. The following morning they were given oral praziquantel, 25 mg/kg; 1 hour later, they were given a saturated solution of 30 g of MgSO4 dissolved in water. Subsequently, 3–4 consecutive posttreatment stools were collected. Worms were recovered by a series of washing steps  or mebendazole (500 mg), and patients with trematode infections were given praziquantel .Adult worms were identified by direct light microscopy while still alive; those that needed further examination were fixed in 10% formalin and stained with Semichon acetocarmine, mounted on a slide, and measured , as measured by enumeration of eggs per gram of feces. Species infection rates (number of expelled worms) were descriptively analyzed by using SPSS version 11.0 software  and χTrichuris trichiura (whipworm) nematode eggs were found in 58.2% of the stool samples. A total of 64.9% were infected with small trematode eggs (<50 μm long), and 39.5% were infected with Ascaris lumbricoides (roundworm). Hookworm eggs (3.1%) and large (>50 μm long) trematode eggs (0.8%) were infrequently seen  and 52 women (8.5%), were selected and submitted stool for examination. Fecal egg examinations showed that 554 persons (90.1%) were positive for helminth parasites . Trichurtly seen . Multipa2 43.56, p<0.05). The infection rate for small trematode infection in men also differed significantly between age groups; it was significantly higher for those >40 years of age . In contrast, women did not show a significant difference in infection rates between age groups .On the basis of egg count data, small trematode infection prevalence differed significantly between men (68.7%) and women (23.1%)  ; 344 (86.2%) of 399 shed <1,000 epg, and 55 (13.8%) of 399 shed 1,000–9,999 epg. Infection intensity differed significantly between those  p<0.05) .A. lumbricoides was 39.3% in men and 42.3% in women. There was a significant increase in prevalence with age only in women . Infection with T. trichiura infection did not differ significantly by sex or age (p>0.05).The prevalence of C. sinensis and 4 species of intestinal fishborne zoonotic flukes were identified  were Haplorchis pumilio (632 × 291), H. taichui (756 × 421), H. yokogawai (760 × 400), and Stellantchasmus falcatus (468 × 298). Prevalence of intestinal flukes was H. pumilio, 100%; H. taichui, 69.7%; H. yokogawai, 6.1%; and S. falcatus, 3.0%. H. pumilio was the most common trematode (90.4%) of all worms isolated; 13,734 adult worms were isolated from 33 persons (mean 416.2); 1 patient expelled 4,525 worms. The plantborne intestinal pig trematode Fasciolopsis buski was isolated from 1 patient.Trematodes responsible for releasing small eggs were identified by using morphologic characterization of adult stages expelled from patients. A total 15,185 adult worms were collected from 33 patients. The number and prevalence of individual species of expelled trematodes are shown in entified ; C. sineF. buski.Multiple infections with FZTs were common : 54.5% oMelanoides tuberculata) and suitable vertebrate intermediate (fish) and reservoir hosts  for FZTs are common in this country  and women (23.1%). Differences in liver infections with The relationship between prevalence and intensity of infection and age of the host is also a characteristic of FZT epidemiology (


Data on the epidemiology and cost of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in Italy are limited. This retrospective, population-based study was designed to determine the incidence of HZ and the proportion developing PHN in Italy and the associated medical resource utilisation and costs. It focused primarily on immunocompetent patients aged ≥50 years who would be eligible for preventive vaccination.Data were extracted from a primary-care database and national hospital-discharge records covering four major regions in Italy for 2003-2005. Cases of HZ and PHN  were identified by ICD9-CM codes and, additionally for PHN, prescription of neuropathic pain medication.Over 3 years, 5675 incident cases of HZ were documented in adults, of which 3620 occurred in immunocompetent patients aged ≥50 years (incidence of 6.31 per 1000 person-years [95% CI: 6.01-6.62]). Of the immunocompetent patients aged ≥50 years with HZ, 9.4% (95% CI: 8.2-10.7) and 7.2% (95% CI: 6.2-8.2) developed PHN1 and PHN3, respectively. Increasing age, female sex, and being immunologically compromised conferred increased risk for both HZ and PHN. Overall, about 1.3% of HZ and almost 2% of PHN cases required inpatient care, with 16.9% of all HZ-related hospitalisations due specifically to PHN. In patients aged ≥50 years, mean stay was 7.8 ± 5.4 days for HZ and 10.2 ± 8.6 days for PHN, and direct costs associated with inpatient care were more than 20 times outpatient costs per HZ case (mean ± SD: €2592 ± €1313 vs. €122.68 ± €97.51) and over 5 times more per episode of PHN (mean ± SD: €2806 ± €2641 vs. €446.10 ± €442.97). Total annual costs were €41.2 million, of which €28.2 million were direct costs and €13.0 million indirect costs.This study, the largest to date on the epidemiology and economic impact of HZ and PHN in Italy, confirms the considerable disease and economic burden posed by HZ. As HZ and PHN disproportionately affect the elderly, without intervention this problem is likely to grow as the proportion of elderly in the Italian population continues to increase. Herpes zoster (HZ), caused by reactivation of latent varicella zoster virus present in the dorsal root ganglia, is an acute disease characterised by a vesicular rash. The lifetime risk of developing HZ is about 20-30% -3. HowevWhile pain associated with the acute infection tends to resolve with the rash, post-herpetic neuralgia (PHN), an intractable pain in the dermatome affected by HZ, remains a common complication. Precise definitions of PHN vary, but it is estimated to affect 10-20% of all patients with HZ aged >50 years -8 and upAfter Japan, Italy has the highest proportion of elderly people in its population , and yetThe present study was designed to provide additional data on the incidence of HZ and to determine the proportion of HZ cases developing PHN in Italy. The study also sought to determine the associated medical resource utilisation and costs, and to estimate the total economic burden of HZ and PHN in Italy. Both parts of the study focused on the immunocompetent population aged ≥50 years, who would be eligible to receive a preventive vaccine that will be available soon in the European Union.This was a retrospective, population-based study in which epidemiological and economic data were estimated in adult men and women, primarily aged ≥50 years, from a large primary-care database and national hospital-discharge records.th Revision, Clinical Modification [ICD9-CM]), drug prescriptions , hospital referrals and diagnostic investigations for over 1 million patients . For each year of the study period, each subject was considered exposed for the entire year. Crude and adjusted incidence rate ratios were estimated from these models given that the poisson regression coefficients are the logarithm of the rate ratio. Given that the study design was a two-stage design because data from primary care were clustered by GPs, and those from hospitalisations were clustered by region, the reported 95% confidences intervals were calculated by taking into account the fact that people were clustered within GP practices (for the primary care data) and within region  . The anaMedical resource consumption for outpatient care in immunocompetent patients aged ≥50 years was extracted from the SIMG database for the period 2003-2005. The follow-up period for cases of HZ was 1 month from diagnosis, while cases of PHN were followed for at least 6 months from initial diagnosis. Estimated unit costs for outpatient visits, diagnostic tests and procedures were based on the average actual cost of each visit/test/procedure across all individual records in the SIMG database in 2005. Costs of medication for HZ and PHN were calculated based on drug prices in the 2005 edition of the Prontuario Farmaceutico Nazionale (PFN) . The amoMedical resource consumption and costs for inpatient admissions and hospital day care between 2003 and 2005 in immunocompetent patients aged ≥50 years were obtained from the hospital-discharge registries. Hospital costs were expressed in 2005 prices using the general price index before aggregating all direct costs.The overall direct costs of HZ and PHN were calculated by multiplying the mean cost of each case with the expected total number of cases in the Italian population.Indirect costs associated with HZ and PHN were based on likely productivity losses for individuals aged 50-64 years. A focus group of experts, including a neurologist, a geriatrist, a dermatologist and a pain specialist, led by an external moderator, reached a consensus on the number of working days lost due to HZ or PHN. Average daily wage data were taken from Consiglio Nazionale dell'Economia e del Lavoro (CNEL) labour cost statistics  and workTotal cost per episode of HZ and PHN was estimated from both the third-party payer and societal perspective. The economic burden of HZ and PHN  was calculated as the sum of the estimated total outpatient costs, total hospitalisation costs, and total indirect costs (productivity loss) described above.In total, 5675 incident cases of HZ were documented over the 3-year study period, with 1843, 1898 and 1934 cases recorded in 2003, 2004 and 2005, respectively. Patients aged ≥50 years accounted for 4119 (72.6%) incident cases, of which 3620 (87.9%) occurred in immunocompetent patients. Among men and women aged ≥50 years, this corresponded to an incidence of 6.65 per 1000 person-years (95% CI: 6.35-6.97), or 6.31 per 1000 person-years (95% CI: 6.01-6.62) in the immunocompetent population. In comparison, the incidence was 4.31 per 1000 person-years (95% CI: 4.11-4.52) for the adult population as a whole, or 4.07 per 1000 person-years (95% CI: 3.88-4.27) for the immunocompetent adult population. Incidence increased markedly with age, with the peak occurring in those aged 75-79 years  were found to be independently associated with an increased risk of acquiring HZ infection.With over 22 million people aged ≥50 years living in Italy in 2005 [In total, 452 cases of PHN1 were documented in the adult population over the 3-year study period, of which 350 (77.4%) cases also met criteria for PHN3. Thus, 8.0% (452/5675) (95% CI: 7.0-8.9) of the adult population with HZ experienced PHN lasting at least 1 month and 6.2% (350/5675) (95% CI: 5.3-7.0) experienced PHN for at least 3 months. The proportion of patients with HZ who developed PHN was highest in those aged ≥50 years  (95% CI: 7.7-10.2) vs. 6.6% (158/2379) (95% CI: 5.5-7.7) for PHN1 and 6.9% (228/3296) (95% CI: 5.8-8.0) vs. 5.1% (122/2379) (95% CI: 4.1-6.1) for PHN3. Over 65% of cases of both PHN1 and PHN3 in primary care were documented in female patients.In the multivariate analysis, classical risk factors  were found to be independently associated with an increased risk of developing PHN.Over the 3-year study period, the average incidences of hospitalisation for primary diagnoses of HZ and PHN were 10.34 and 1.89 per 100,000 person-years, respectively, in immunocompetent patients aged ≥50 years. The total incidence rose to 20.31 per 100,000 person-years (17.45 for HZ and 2.86 for PHN) in this population when both primary and secondary diagnoses on SDOs were combined. Corresponding figures for the adult immunocompetent population as a whole were 5.55 per 100,000 person-years for a primary diagnosis (4.61 for HZ and 0.94 for PHN) and 9.60 per 100,000 person-years for primary and secondary diagnoses combined (7.94 for HZ and 1.66 for PHN). Within the older population, rates of hospitalisation increased progressively for each decade up to 85 years  of cases were referred to a specialist . The mean number of specialist visits was 0.2 for each case of HZ, increasing slightly with age. Antivirals were used in 78.4% of cases, while 12.2% were treated with anticonvulsants, 5.1% with opioid analgesics, 3.2% with non-opioid analgesics and 3.0% with TCAs. Overall, 28.0% (1012/3620) of cases underwent further diagnostic or laboratory examinations, with the mean number of procedures and examinations being 2.6 for each case of HZ, increasing with age (age class range 2.3-2.9).For immunocompetent patients aged ≥50 years, the mean number of primary-care consultations for each case of PHN1 and PHN3 was 11.9 and 12.0, respectively. In total, 74.1% (206/278) and 73.7% (154/209) of PHN1 and PHN3 cases were referred to a specialist , with a mean number of specialist visits of 3.5 for each case of PHN1 (age class range 2.2-4.3) and 3.9 for each case of PHN3 (age class range 2.5-4.7). Anticonvulsants were prescribed in 51.4% and 46.4% of PHN1 and PHN3 cases, respectively. Corresponding figures for opioid analgesics were 27.0% and 26.3% and for TCAs were 15.1% and 13.4%, respectively. Drug utilisation was higher overall for cases of PHN3.For immunocompetent patients aged ≥50 years, the mean outpatient cost (±SD) for each case of HZ was €122.68 ± €97.51 (at 2005 prices), of which 83.1% was due to the cost of medications. Diagnostic radiology or ophthalmological and otological examinations (6.8%), laboratory investigations (6.6%) and specialist visits (3.6%) accounted for the remaining costs.For immunocompetent patients aged ≥50 years, the mean outpatient cost (±SD) for each case of PHN1 was €446.10 ± €442.97 and for each case of PHN3 was €416.65 ± €406.30 (at 2005 prices), of which laboratory investigations and investigative procedures accounted for 58.1% and 63.4% of total costs for PHN1 and PHN3, respectively. Medications accounted for about a quarter of total outpatient costs, at 27.7% and 21.5% for PHN1 and PHN3, respectively. Specialist referral was sought in 74.1% (206/278) of PHN1 cases and 73.7% (154/209) of PHN3 cases; these visits accounted for the remaining 14.2% and 15.1%, respectively, of total outpatient costs.Of the total hospitalisations for HZ, 92.3% were related to major skin disorders, eye disorders, infections of the nervous system (excluding meningitis) and viral illnesses. For immunocompetent patients aged ≥50 years, the mean (±SD) inpatient stay for HZ was 7.8 ± 5.4 days, which increased with age (6.5 ± 5.5 days for 50-54-year-olds vs. 8.9 ± 5.6 days for those aged >85 years). Of the total hospitalisations for patients with PHN, 92.6% were related to cranial and peripheral nerve disorders and infections of the nervous system (excluding meningitis). For immunocompetent patients aged ≥50 years, the mean (±SD) inpatient stay for PHN was 10.2 ± 8.6 days and showed no age-related trend.For immunocompetent patients aged ≥50 years who were hospitalised, the mean cost (±SD) per patient of inpatient care in the period 2003-2005 was €2592 ± €1313 for HZ and €2806 ± €2641 for PHN.The mean direct medical cost per HZ episode in Italy was calculated as €166, which comprised outpatient costs of €123 per episode, to which €43 was added as the mean cost of hospitalisation per HZ episode, computed as the cost of hospitalisation spread over the total number of expected cases , the primary focus of the study, was comparable with that reported in other studies ,26, inclHZ incidence was more common in women than men, a finding supported by several other studies ,26-28, aPHN, which in our study was identified by ICD9-CM codes or prescriptions for specific neuropathic pain medications, affected 9.4% of immunocompetent patients aged ≥50 years, of whom about 77% continued to have pain 3 months after HZ onset. These rates are consistent with those reported for several other community-based studies -33. HoweCertain limitations of this study may have resulted in an underestimation of the proportion of PHN. In Italy, primary-care physicians manage most cases of HZ but only about a quarter of related cases of PHN because most cases of PHN are managed by specialists. Thus, this study did not capture cases of PHN that were not seen by a primary-care physician or referred to hospital. This demonstrates that use of the SIMG database to evaluate PHN in Italy has limits as it excludes patients who may have approached specialists directly. In addition, estimating the number of PHN cases retrospectively on the basis of drug prescriptions for pain relief rather than on the basis of pain severity may have led to an underestimation of the proportion of HZ cases that developed PHN because less serious cases which were not treated with drugs and serious cases where patients refused drug treatment may not have been detected. While our estimates of HZ incidence are robust, those for the proportion of patients with HZ who developed PHN are less reliable and are probably underestimates. Indeed, it is arguable that no study has produced reliable estimates of the proportion of HZ cases that develop PHN, and this is exemplified by the variation seen between studies ,26,34,35Some patients with HZ and PHN require hospital treatment, including inpatient care. Overall, about 1.3% of HZ cases required inpatient care in this study, increasing to almost 2% where only PHN cases were considered. At 9.60 per 100,000 person-years, the incidence of hospitalisations for HZ or PHN was higher in our study than rates reported in other European countries or North America ,38 despiWe also estimated the economic impact of HZ and its complications in terms of direct healthcare costs as well as estimating likely indirect costs. As this study has demonstrated, HZ and PHN, the most common complication of HZ, impose a significant economic burden on the Italian population, with total costs for patients aged ≥50 years exceeding €41 million a year. At €28.2 million, direct medical costs accounted for just over two-thirds of total costs. Indirect costs associated with lost productivity were responsible for almost a third of total costs in the older population and reflect the debilitating nature of HZ and PHN among older people of working age. Although the recent prospective study in Piemonte did not extrapolate data to obtain total direct costs for the Italian population, at €136.06 per observed outpatient case of HZ, €360.60 per case treated in the outpatient setting, and €4082.59 for each hospitalised case  direct costs per case were broadly similar to our estimates .Studies have consistently shown that HZ and especially PHN significantly impact patients' quality of daily life -14 and, Previously, it has been shown that patients requiring hospitalisation are likely to have more severe HZ or PHN, and thus, hospital-discharge data provide a measure of more serious cases . In the It is difficult to make direct comparisons between the present study and studies carried out in other countries to assess direct and indirect costs associated with HZ and PHN because of differences in healthcare practices and pricing. Nonetheless, as others have concluded, the economic and social costs of managing HZ and its complications represent an important burden on healthcare services and society , a view Our study had a number of limitations in addition to those already discussed. The higher percentage of home consultations in the very elderly, which may not have been recorded in the SIMG database, may have led to underestimation of incidence in the very old. Hospital-discharge data do not state unequivocally that HZ or PHN was the initial reason for hospitalisation, which may have affected the estimates of disease burden. As GP prescriptions could not be linked to specific PHN diagnostic codes and the drugs may have been prescribed for conditions other than PHN, outpatient costs for PHN may have been overestimated. Indirect costs were based solely on productivity losses due to absence from work and were derived from expert opinion, an approach that may limit the reliability of indirect cost estimates. Experts agreed that HZ patients will usually loose between 7 and 10 working days, while in case of serious pain 10-15 working days are reasonably lost due to PHN. Accordingly, the conservative assumption of 7 and 10 working days lost due to HZ and PHN, respectively, was made in the estimate of indirect costs. However, all focus group specialists stressed the extreme variability of the non-acute phase. Finally, when combining the results from the epidemiological and economic parts of the study it was not possible to obtain a measure of the reliability of estimates of the total cost of HZ and PHN .In conclusion, this study has demonstrated that HZ and related complications such as PHN impose a considerable disease and economic burden in Italy. While our estimates of HZ incidence in the Italian population can be considered robust, those for the proportion of patients with HZ who develop PHN are likely to be underestimates and would best be assessed in prospective studies. As HZ and PHN disproportionately affect the elderly, without intervention the burden to patients and society is likely to grow as the proportion of elderly in the Italian population continues to increase.LN provided consultancy advice to Sanofi Pasteur MSD to assist with developing the study. AG has provided consultancy advice to Sanofi Pasteur MSD. AV has provided consultancy advice to Sanofi Pasteur MSD and Novartis, and has received honoraria for lectures from these companies and from GlaxoSmithKline and Menarini. He has also received honoraria for preparing educational materials for Menarini. LEG, MM and PP are consultants for Informa, Rome, who coordinated this study. MB, LS and RM are employees of Sanofi Pasteur MSD, a provider of a herpes zoster vaccine approved in the European Union.LEG participated in the study design, analysis of data and drafting of the study report and helped to draft the manuscript. MM and PP participated in the study design and analysis of data. LN, AG and AV validated the protocol, design and final results of the study. MB, LS and RM participated in the study design, coordinated the study and validated the study results and study report. All authors read and approved the final draft manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/10/230/prepub


Several studies have shown that testing for high-risk human papillomavirus (HPV) types results in an improved sensitivity for CIN2+, compared with cytology, although with a somewhat lower specificity.We obtained follow-up results, with at least one smear after participation in the HART study, which compared HPV testing (HC-II) with cytology as a primary screening modality.With a median follow-up of 6 years, 42 additional cases of CIN2+ were identified; women who were HPV positive at baseline were more likely to develop CIN2+ than those who were HPV negative (hazard ratio (HR) 17.2; 95% confidence interval (CI) (9.3–31.6)) and the risk increased with increasing viral load. Compared with HPV-negative women (relative light unit (RLU) <1), the HR (95% CI) was 5.4  for 1–10 RLU and 25.5  for RLU ⩾10. Positive cytology (borderline or worse compared with negative) was also predictive of developing CIN2, although to a lesser extent ). Only one case of CIN3 and three cases of CIN2 were found in women who showed a positive cytology result but were HPV negative at baseline.After 5 years of follow-up, CIN2+ occurred in 0.23% of women who were HPV negative at baseline compared with 0.48% of women who showed a negative cytology result, indicating a much longer low-risk interval for CIN2+ after HPV testing. The introduction of cervical screening programmes based on cytology has led to a substantial reduction in the incidence of cervical cancer in countries in which it has been adequately organised , which was placed into specimen transport medium for transportation to one of two laboratories. This second sample was tested for high-risk HPV types  using the Digene (now Qiagen) Hybrid Capture II kit (HC-II). Patients were considered HPV positive if their result was above the 1 relative light unit (RLU) control value, in keeping with the manufacturer's instructions. Risk associated with increasing RLU levels was also investigated to determine the impact of viral load.Women with mild dyskaryosis or worse or with two to three inadequate cytology results were referred to colposcopy. Women with a borderline smear or an HPV-positive result (or both) were randomised into two equal groups to receive immediate colposcopy or a further cytology and HPV test in 6–12 months. Those with both a negative cytology and a negative HPV test result were considered disease free and continued routine screening. However, 460 of these women were randomly selected for colposcopy to ascertain disease rates in this subgroup of women.Full details of testing and management of women at baseline are given in the baseline paper , the national computerised call/recall NHAIS system  (London) or a combination of both systems . Follow-up colposcopy and histology results were obtained for each centre using their internal computer systems.Criteria for referral to colposcopy varied between different sites: Birmingham – one mild dyskaryosis or worse; three borderline or inadequate smears. After biopsy, all women with high-grade disease were treated, and some cases of low-grade disease as well. Edinburgh – one moderate dyskaryosis or worse, or glandular abnormality; two mild dyskaryosis; three borderline; three inadequate smears. An option of treatment or conservative management was offered to patients with biopsy-confirmed CIN1 and all CIN2 or worse cases were offered treatment. London – one mild dyskaryosis or worse; three borderline or inadequate smears. An option of treatment or conservative management was offered to patients with biopsy-confirmed CIN1 and all CIN2 cases or worse were offered treatment. Manchester – one mild dyskaryosis or worse; three borderline or inadequate smears. After biopsy, all cases of high-grade and some cases of low-grade disease were treated. Mansfield – two mild dyskaryosis or worse; two borderline or three inadequate smears. After biopsy, all cases of high-grade and some cases of low-grade disease were treated.Additional ethical approval for the follow-up stage of the study was obtained by the MREC involved with the original HART study .All eligible women from the baseline study were included (vs 97.1% previously) and for cytology of 82.1% (vs 76.6% previously). For CIN3+, sensitivity was 96.1% for HPV (97.1% previously) and 82.9% for cytology (82.6% previously).Initial results for the baseline period have been published  had a further smear more than 1 year after baseline (50 HPV negative and 3 positive), but among them, no high-grade disease was identified. Three women had an ungraded CIN at some stage in their follow-up, of whom two had an additional histological diagnosis within a period of 2 months, which confirmed CIN3 . The remaining woman had no further follow-up recorded and this result was taken to be CIN2 .n=9574) were identified as having CIN2+ at some stage. Eight (30%) of them were identified in the baseline year and the remaining 19 (70%) after this period. Including disease found at baseline, the risk of developing CIN2+ at 1, 3, 5 and 8 years after a negative HPV test result was 0.09, 0.12, 0.23 and 0.61%, respectively. P<0.0001). There is a clear increase in incidence of CIN2+ as the RLU ratio increases. Compared with an RLU ratio <1, the HR (95% CI) for CIN2+ was 5.4  for 1–10 RLU and 25.2  for RLU ⩾10 .A total of 27 (0.28%) women with a negative HPV test at baseline (n=9782) were identified as having CIN2+ at some stage. Nineteen (39%) of them were identified in the baseline year and the remaining 30 (61%) after this period. Including any disease found at baseline, the risk of developing CIN2+ at 1, 3, 5 and 8 years after a normal cytology result was 0.21, 0.28, 0.48 and 1.04%, respectively. vs 2.44% at 3 years, 0.28 vs 3.40% at 5 years and 0.84 vs 3.40% at 8 years , P<0.0001).In all, 49 (0.50%) women with a normal cytology result at baseline  had CIN2+, including 4 identified within the first year. vs none after HPV testing) (These results confirm previous reports of a longer low-risk period after a negative HPV test result than after a negative cytology result(Women with HPV positive or cytology borderline results (or both) were randomised to either immediate colposcopy or referral to a further smear/HPV test in 12 months. The rate of CIN2+ in the follow-up period was similar regardless of the randomisation group. Therefore, results were unchanged regardless of whether women are referred for immediate colposcopy or managed by follow-up screening. Some overtreatment of lesions with CIN1 (or less) based on the initial biopsy results will lead to lower disease rates during follow-up. We recorded treatment of 17 of 65 (26.2%) women with histologically confirmed CIN1 and 26 of 146 (17.8%) women with a biopsy indicating less than CIN1.vs HPV testing in younger women, wherein both tests have a higher positivity rate.In addition, the histology results in the follow-up phase were not centrally reviewed because of concerns regarding contacting women if there were discrepancies. Therefore, especially for CIN2, which is known to have substantial inter-reader variability and also uncertain progressive potential, it is possible that not all of these were progressive lesions. An exit screen in which all women receive both tests would help to minimise any ascertainment bias. In addition, this study was performed in women aged 30–60 years so that it does not provide any evidence for the relative benefits of cytology In summary, HPV testing offers improved protection from CIN2+ after a negative test result compared with the protection afforded from a normal cytology result. The risk of developing CIN2+ after a negative HPV test result was extremely low at 5 years (0.23%) and was comparable with cytology at 3 years (0.28%). These results provide additional support for using HPV as the primary screening test, and indicate that the very high sensitivity of HPV testing can not only lead to a more effective screening programme but the resulting high negative predictive value can safely allow longer screening intervals and result in a more cost-effective programme as well.


Median time to progression was 5.1 months and median survival time 7.4 months. This combination appears well tolerated and shows promising clinical activity.Potential synergistic interaction between gemcitabine (GEM) and epirubicin (EPI) in pancreatic cancer have been described previously. The maximum-tolerated dose in this trial was GEM 1000 mg m Pancreatic cancer is one of the most aggressive human cancers with an extremely poor prognosis. In 1998, gemcitabine (GEM) was approved for use in the palliative treatment approach .In vitro studies in solid tumour cell lines have demonstrated that pretreatment of cancer cells with the anthracycline epirubicin (EPI), followed by administration of GEM, inhibits proliferation and increases the rate of DNA fragmentation  ⩾60 and a left ventricular ejection fraction measured by multiple electrocardiogram-gated radionuclide study (MUGA-scan) higher than 50%. Baseline laboratory requirements were defined as described elsewhere  was administered as a 30-min i.v. infusion on days 1 and 8; EPI  as an i.v. bolus injection over a period of 5 min prior to GEM on day 8 of each 21-day cycle. In phase I the dose escalation to a maximum of six levels consisted of: Step 1: GEM 800 mg mDose-limiting toxicity was defined, using the World Health Organization (WHO) criteria  with the next higher dose having at least two patients who experienced DLT. A DLT was defined as described elsewhere  criteria were used for safety assessment . The significance level for each hypothesis test was 5%. Median time to progression and overall survival time was calculated according to the Kaplan–Meier product-limit method. Subgroups were compared using the log-rank test.Between May 2000 and 2003, a total of 40 symptomatic patients were enrolled in the study . A total−2 and EPI 45 mg m−2), was found to be the MTD for the phase II part. Overall, 28 patients were treated with GEM 1000 mg m−2 and EPI 45 mg m−2.Three patients were entered at each dose level 1, 2 and 3 in the phase I part. Six patients were assigned to dose level 4. At that dose level, two of six patients experienced DLT, which consisted of grade 3 neutropenia and anaemia in one patient and a febrile grade 4 neutro- and thrombocytopenia in a second patient. Therefore, dose level 3  and one patient of phase II (neutropenia). In seven (25%) patients dose reduction of both drugs to 75% was necessary while one patient received dose reduction to 50% due to leukopenia grade III in one cycle, and treatment delay for 1 week in another cycle.Overall, the 28 patients who were treated with the MTD of GEM 1000 mg mOne patient at this dose level experienced grade 3 nausea/vomiting. Chemically induced phlebitis due to EPI was noted only in one other patient. Hospitalisation was necessary for another patient due to pneumonia. No major hepatic, renal, cardiac and neurologic toxicities were seen as well .The overall response rate was 23% (95% CI: 0.29–0.62) based on nine of 40 patients with partial response. The median time to response was 3 (range 2.5–3.7) months, and the median duration of response was 8.2 (range 4–12) months. Stable disease (SD) occurred in 14 of 40 (35%) patients. The remaining 17 (42.5%) patients showed progressive disease. Median time to disease progression for all patients was 4.2 (range 2–12) months.P=0.01).The 6 months and 1-year survival rates were 55% (22/40 patients) and 22.5% (9/40 patients), respectively. The median overall survival time was 7.4 (range 2–21.8) (95% CI: 5.1–9.9) months. For patients with tumour response (9/40 patients), the median survival was 12.6 (range 10.7–21.8) months, and the probability of surviving beyond 1 year was 55%. Patients with objective tumour response survived significantly longer than patients with no tumour response (P<0.001).Thirty-seven patients with tumour-related symptoms were considered evaluable for clinical benefit response. In 10/35 (29%) patients suffering from pain at study entry, pain intensity and/or analgesic use was reduced at least by 50% compared to baseline values, and 18 remained stable in this category. Improvement of KPS occurred in 13 (35%) patients and performance status remained stable for 20 (54%) patients during at least 4 weeks. Eight patients (21.6%) had a weight gain of ⩾7% from baseline during the study. Improvement of the quality of life during treatment measured and expressed with the Spitzer-activity-index was seen in 15 of 37 (40.5%) patients. In the final assessment, a total of 18 patients were classified as clinical benefit responders, yielding a clinical response rate of 49% (95% CI: 0.29–0.62). We observed a significant correlation between clinical benefit response and objective tumour response as well  with our results. −2+EPI 60 mg m−2+granulocyte colony-stimulating factor. Recently, a phase III trial with GEM in combination with EPI, 5-FU and cisplatin vs GEM was published by Comparable objective results were published by In our study, we observed a clinical benefit response in 49% of symptomatic patients. This compares favourably with the rate of clinical benefit response in the GEM+EPI studies by In conclusion, this combination chemotherapy of GEM and EPI was well tolerated and feasible at the recommended dose level. The regimen is active with a high rate of clinical benefit responders. Whether addition of EPI to GEM is comparable to the combination of other drugs  and GEM should be further evaluated in randomised phase III trials.


Information regarding hepatitis C virus genotypes and subtypes circulating in Pakistan and various risk factors for their transmission are not known well. The specific objective of this study was to find out the frequency of various HCV genotypes present in well-characterized Pakistani HCV isolates and their possible routes of transmission.A total of 3351 serum samples were tested by type-specific genotyping assay. Out of 3351 HCV RNA positive patients, 2039 were males and 1312 were females. As regard as genotyped samples, 2165 belonged to Punjab region, 823 belonged to N.W.F.P., 239 to Sindh and 124 patients were from Balochistan.Out of the total 3351 tested serum samples, type-specific PCR fragments were observed in 3150 (94.00%) serum samples. The distribution of genotypes of the typeable samples as determined by this assay, was as follows: 1664 (49.05%) genotype 3a; 592 (17.66%) genotype 3b; 280 (8.35%) genotype 1a; 252 (7.52%) genotype 2a; 101 (3.01%) genotype 1b; 50 (1.49%) with genotype 4; 25 (0.75%) with 3c; 27 (0.80%) genotype 2b; 6 (0.18%) with subtype 5a; 5 (0.15%) genotype 1c; 4 (0.12%) with subtype 6a; 3 (0.09%) genotype 2c; and 161 (4.80%) patients were infected with mixed infection. Two hundred and one (5.99%) serum samples were found untypeable by the present genotyping system. More than 86% and 72% patients with genotypes 3a and 3b respectively had received multiple injections in past. For genotypes 1a and 1b the route of transmission was major/minor surgery along with unknown reasons. Majority of the cases with type 2a, 2b and indeterminate genotypes were sporadic. Mixed infections were common in thalassaemic patients.The most common HCV genotype in Pakistan is type 3a. Regional difference in genotypes was observed only in Balochistan province of Pakistan. More than 70% of the cases were acquired in hospitals through reuse of needles/syringes and major/minor surgery that is very common in this country. Flaviviridae infections with significant clinical problems throughout the world in humans and it is responsible for the second most common cause of viral hepatitis  = 823); the Punjab was represented by Lahore, Gujranwala, Mandi Bahauddin, Multan, Sarghoda, Jehlum, Sialkot, Rawalpindi, Rahim Yar Khan and Faisalabad (n = 2165); the Sindh was represented by Karachi, Hydarabad, Khair Pur, Nawab Shah, Dadu and Mirpur Khas (n = 239); and Balochistan was represented by Quetta, Ziarat and Sibbi (n = 124). The isolates from NWFP, Punjab, Sindh, or Balochistan were designated as NP, PP, SP, or BP, respectively, to identify the origin of the samples. A written informed consent was taken from patients and the data sheet contained demographic of patients, possible route of transmission, area, and estimated time of infection and complete address of the patients with telephone numbers. The study was approved by the ethics committee of the Institute.All the serum samples were received along with specifically designed data sheets at Division of Molecular Virology & Molecular Diagnostics, Centre for Applied Molecular Biology, Lahore from 121 tertiary collection centers situated in different cities/towns of all the four provinces of Pakistan such as North West Frontier Province (NWFP), Punjab, Sindh and Balochistan for the detection of HCV during the course of this study. Pakistan is situated in the western part of the Indian subcontinent, with Afghanistan and Iran on the west, India on the east, and the Arabian Sea on the south. Pakistan is the sixth most populous country in the world. Pakistan is a federation of four provinces (described above), a capital territory and federally administered tribal areas. The total land area is estimated at 803,940 square kilometers. Estimated (2007) population of the country is 169,270,617. Serum samples from chronic HCV carriers showing HCV RNA positivity with all the required information representing the four provinces of Pakistan were included in the study. The N.W.F.P was represented by cities/towns of Peshawar, Mardan, Malakand, Dir, Swat, DI Khan and Bunnu  PCR was carried out for the qualitative detection of HCV RNA using primers corresponding to 5'NCR primers as described previously . BrieflyHCV genotyping was carried out using type-specific HCV genotyping method as described previously in detail . BrieflyEF173931 to EF174030.The 5'UTR region of all the 201 untypable isolates were sequenced in both directions and sequences that were obtained for the first time were submitted to GenBank data base. The Accession Numbers provided for our nucleotide sequences by the GeneBank are from P-values less than 0.05 were considered significant.The data was analyzed and the summary statistic was carried out by a statistical package, SPSS version 10.0 for window. The results for all variables were given in the form of rates (%). Chi Square and Fisher's Exact tests were used for categorical variables that measured association among categorical variables. All data are presented as mean values or number of patients. Figure EF173931 to EF174030.Table The distributions of HCV genotypes were similar in male and female patients.n = 172) belonged to genotype 1a, 2.72% (n = 59) genotype 1b, 0.18% (n = 4) genotype 1c, 6.46% (n = 140) genotype 2a, 0.69% (n = 18) genotype 2b, 0.09% (n = 2) genotype 2c, 52.10% (n = 1128) genotype 3a, 16.53% (n = 358) genotype 3b, 0.64% (n = 14) genotype 3c, 1.15% (n = 25) genotype 4, 0.23% (n = 5) genotype 5a, 0.05% (n = 1) genotype 6a, and 4.34% (n = 101) were dual genotypes. From NWFP 823 cases were grouped after genotyping as follows: subtype 1a in 54 (6.56%); 1b in 21 (2.55%); 2a in 63 (7.65%); 2b in 7 (0.85%); 2c in 1 (0.12%); 3a in 397 (48.23%); 3b in 157 (19.07%); 3c in 7 (0.85%), genotype 4 in 19 (2.30%), 5a in 1 patient (0.12%); 6a in 3 (0.36%); mixed in 42 (5.10%) and untypeable in 51 (6.19%) patients. In Sindh genotype 3a was predominant in being found in 95 (39.74%) of samples followed by 3b (26.35%), 2a (9.62%), 1a (9.2%), 1b (3.76%), 3c (1.25%) and genotype 4 (0.41%). Twelve (5.02%) mixed genotypes were also isolated from this area and 10 (4.18%) samples were found untypeable. Among patients from Balochistan, genotypes 1a (25.8%) was the most prevalent followed by 2a (20.96%), 3a (19.35%), and 3b (11.29%); 1b (9.67%); 2b (10.8%); genotype 4 (4.03%); 1c (0.80%) and 3c (0.80%). Six (4.83%) of the isolates were found with dual infection and 2 (1.61%) were untypeable.Frequency of HCV genotypes were examined by individual Provinces shown in table Table Various possible risk factors responsible for infection transmission with each HCV genotypes are given in table Data so obtained from different parts of the world have focused on the increasing interest of HCV genotyping by mass screening as it is useful for the solution of epidemiological questions and development of vaccines against HCV. Furthermore it has been shown to be beneficial to facilitate therapeutic decisions and strategies -27. It hSubstantial regional differences appear to exist in the distribution of HCV genotypes. Thus knowledge on the distribution of various genotypes in our country is essential for its prognostic implications in chronic hepatitis C infection. In the present study the frequency of various genotypes of HCV present in Pakistan and various risks for possible transmission were observed. All serum samples tested were HCV-RNA positive by PCR and could thus be genotyped. However, genotype-specific PCR products were seen in about 94% serum samples by this molecular biology-based system that is an excellent percent of the sample size. The data of the present study correspond well to previous studies, in which genotypes or serotypes were determined from other regions of the world -31. The When the results of the present study on HCV genotypes were compared to the genotyping results obtained in other studies from Pakistan ,22, it wIn order to discern if there are any regional differences in HCV genotype distribution in Pakistan, the distribution for this population was examine by individual Provinces. No regional difference with respect to HCV genotype distribution was seen in the Provinces of Punjab, N.W.F.P and Sindh where the most prevalent genotype is 3a followed by 3b. But a clear difference was observed in the Province of Balochistan where the predominant genotype found was 1a followed by 2a and 3a. Balochistan shares a long boarder with Iran in the west where genotype 1 is the predominant genotype in the region . It is qSome studies suggest that different types of HCV may be associated with different transmission routes. In the present study majority of the patients seem to have more than one route of transmission however we took the most probable one for data analysis. In Pakistan genotype 3a is the most prevalent genotype and more than 86% patients with genotype 3a received multiple injections. It is quite possible that this type was spread in Pakistan by doctors, vaccination teams and other medical persons using non-disposable syringe before 1990 when one syringe was used for injections to all attended patients. This type of practice is still there in the rural areas of the country. This observation is supported by a study where subtype 3a appeared to be prevalent among injection drug users and it is believed that it was introduced into North America and the United Kingdom with the widespread use of heroin in the 1960s . FurtherIt appears that more than 70% of the cases were acquired in hospitals or other medical facilities because a large number of subjects 61.45%) received therapeutic injections and surgeries (10.62%) from the clinics of local general practitioners in both government and private hospitals. It has already been reported that Pakistan has one of the highest frequencies of injections in the world and the average number of injections per person per year is more than 9 injections 44–45). Further been reported in the same studies that 49% of patients receive injections at their first outpatient visit where in addition to the unnecessary use of injections, safe injection practices are not followed. Furthermore, previous vaccination have also been alleged to ignore safe injection practices that was largely received at the public health-care facilities including the use of used syringes [–45. Furt% receiveThe predominant HCV genotype in Pakistan is type 3a followed by 3b and 1a. Six HCV genotypes such as 1c, 2c and 3c, 4, 5a and 6a were isolated for the first time from Pakistan during the study. The frequency of genotype 1 was observed to be increasing in this country without any increase in the frequency of genotype 3 that may be very dangerous in coming 15–20 years. Regional difference in genotypes was observed only in Balochistan province of Pakistan. More than 70% of the cases in Pakistan are hospitals acquired.The author declares that they have no competing interests.SR conceived of the study, participated in its design and coordination and gave a critical view of manuscript writing. MI collected epidemiological data and analyzed the data statistically. MI carried out the molecular genotyping assays. All the authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


To describe an evaluation protocol for pediatric stone formers for risk assessment and management strategies.Between 2002-2006, 2618 children of age three months to 15 years were evaluated for stone disease. Evaluation included demographics, history, anthropometry, diet, ultrasound, X-ray KUB, IVU, blood and 24h urine chemistry and cultures. Stones were analyzed by IR spectroscopy.The median age was seven years with a M:F ratio of 2.2:1. Of the 2618 patients, 2216 presented with normal renal function and 402 with renal failure. Main symptoms were abdominal pain (33%), flank pain (38%) and fever (38%). Renal failure patients also had shortness of breath (38%) and oligo-anuria (26%). Children were malnourished with height and weight deficits in 65% and 76% respectively. Diet was low in protein (74%), calcium (55%) and fluids in (55%), high in oxalate (55%), sodium (39%), purines (42%) and refined sugar (41%). Overall urine cultures were positive in 1208 (46%) with E. coli (38%) and Klebsiella (8%).Stone distribution was renal in 64%, ureter in 8%, bladder in 18%, bilateral in 40% and multiple sites in 18%. Median stone size was >1.5-2.0 cm. The frequency of compounds in stones was ammonium urate (58%), calcium oxalate (63%), uric acid (6%), calcium phosphate (12%) and struvite (8%). Metabolic abnormalities included hypovolumia (31%), hypocitraturia (87%), hyperoxaluria (43%) and hyperuricosuria (26%). Dietary and medical treatment corrected risk factors in two-thirds of patients with a recurrence rate of about 1.15%.An evaluation based on history, imaging, diet, metabolic analysis and stone type can help to tailor management strategies. Pakistan lies in the middle of the Afro-Asian stone belt stretching from Sudan and Egypt in the West to Philippines in the East, geographically falling within the tropical and subtropical regions. Historically, the first survey of stone disease in the subcontinent was undertaken by Col. McCarrison of the Indian Medical Service in 1931 where the highest incidence was found in Sindh and Punjab provinces which now constitute Pakistan. However,On this backdrop, evaluation of children with stone disease becomes of paramount importance both in terms of management and development of preventative strategies. This paper describes our approach to evaluate children with stone disease so as to develop a meaningful diagnostic protocol for developing countries. This can help in the management and prevention of stone recurrence in the pediatric population.Between January 2002 and December 2006, 2618 pediatric patients of age three months to 15 years, presented with urolithiasis in the outpatient department (OPD) and Emergency room (ER) of a tertiary care hospital. Of these 2618 patients, 2216 (85%) had normal renal functions and 402 (15%) had associated renal failure. In the renal failure group, 105 (26%) were oligo-anuric and 297 (74%) were non-anuric.All patients presenting to the OPD or ER were evaluated according to the protocol listed in . All infDepending on the associated clinical conditions i.e. renal failure, advanced uremia, urosepsis, the following investigations were undertaken on case to case basis. Arterial blood gases (ABGs), culture of blood, serology for Hepatitis B and C, clotting profile and X-ray chest. These patients required resuscitation and early intensive management including dialysis and/or relief of obstruction as initial management.Demographic: Age, sex, family history, socioeconomic status, address of residence including rural/urban location.Anthropometric analyses were evaluated by guidelines of National Centre for Health Statistic (NCHS) by heighDietary analysis: Evaluation of diet was undertaken by a food frequency questionnaire and a seven-day dietary recall proforma. The food frequency evaluated intake of foods associated with urolithiasis. These included animal protein, calcium, oxalate, phosphates, purine, sodium, potassium and refined sugar. Twenty-fRadiology and imaging evaluation: Ultrasound abdomen including kidney, ureter and bladder (KUB) was undertaken in all cases. Intravenous urogram (IVU) was done in patients with normal renal functions requiring extracorporeal shockwave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL). A CT scan was undertaken only as and when required. Radio-isotope scans (nuclear imaging) were used to assess the relative renal function in compromised kidneys.Detailed metabolic evaluation included serum calcium, phosphorus, uric acid, magnesium and proteins. Twenty-four-hour urine collection was done with thymol preservation. Urine collection required catheterization for 24h in small children who were not continent. Tests included creatinine, calcium, uric acid, sodium, potassium, magnesium, ammonium, citrate, oxalate and protein. Cystine was checked qualitatively by sodium nitropruside solution. Adequacy of collection was checked by the formula, Urine creatinine correction = urinary creatinine mg/dl × 24h urine volume ÷ 100 × body weight. Reference ranges for blood and urine chemistry were adopted from Textbook of Pediatrics and HessStone analysis was done by infrared spectroscopy and by florescent infrared spectroscopy (FTIR). Whenever possible separate analysis was done for core, middle and surface of each stone. Chemical examination was undertaken in stones with mixed compounds.Management: UTI was treated according to sensitivity pattern in both groups of patients, with and without renal failure. Definitive management included open surgery for large stone burden in the urinary tract, kidneys with reduced cortex and stones with UTI and structural abnormalities.Minimally invasive treatment, PCNL, ureterorenoscopy (URS), cystolithoclast and ESWL were performed in those with small burden, good renal cortex and without UTI.Dietary and pharmacologic management was undertaken according to identified risk factors. These included dietary intervention, alkalization of urine, allopurinol, pyridoxine and thiazides where indicated. Patients were followed up in a dedicated pediatric stone clinic with repeat metabolic workup between three and 12 months after stone-free status.All the data were expressed as the mean ± SD. The Chi-square and Fisher's exact tests were used where appropriate to analyze categorical data, with P<0.05 taken to indicate statistically significant differences.Demographics: Of the 2216 patients with normal renal function, 1630 (73.5%) were males and 586 (26.5%) were females with a M:F ratio of 2.7:1. The mean age was 7.1±3.8 years with a range of three months to 15 years. Age distribution showed 62 (2.8%) in the age group ≤ 1 year, 387 (17.5%) 1-3 years, 393 (17.7%) in 3-5 years, 873 (39.4%) in 5-10 years, 501 (22.6%) in 10–15 years.In the 402 patients with renal failure, the mean age was 6.9±3.4 years with a M: F ratio of 2.0:1. However, within this group, anuric patients had a low mean age of 4.3±2.9 years with a range of nine months to 14 years.Of the 2216 patients presenting with normal renal function 54% were from an urban area and 46% from a rural area. This was in contrast to the renal failure group where the majority  were from rural areas with a mean travel distance of 160±45 km and mean travel time of 14±6h. Past history of the patients revealed recurrent diarrhea in 23% and history of stone disease in 21%. Patients presenting with renal failure also gave history of previous stone surgery in 78 (22%) and positive family history of stone disease in 241 (60%). The majority of the patients (89%) were from the low income group at Rs. 2000/month ($35), 10.75% from the middle class and 0.25% from the upper middle or rich classes.Clinical Presentation: Common clinical signs and symptoms are given in Hematology and Renal Function Biochemistry: In patients presenting with normal renal function the mean hemoglobin (Hb) was 9.5 g/dl (range 7.5-15 g/dl) and 20% of the patients were anemic (Hb>10 g/dl). Whereas in renal failure patients’ mean Hb was 7.6±2.4 g/dl (range 4.0-13.5) and 69% of the patients were anemic (Hb < 10 g/dl), leucocytosis >16000/cm was found in 32%. At presentation mean serum creatinine was 8.0±3.8 mg/dl, urea 203±74 mg/dl, sodium 134±7.6 mEq/L, potassium 5.1±1.4 mEq/L and bicarbonate 11± 5.2 mEq/L.Anthropometric and dietary analysis: Anthropometric data in 2372 revealed growth deficit and malnutrition in our patient population. Z-score >-1  for height was observed in 775 (35%). The remaining 65% were deficient, Z -1 to −2, 598 (27%), Z -2 to −3, 465 (21%) and 378 (17%) had Z <-3, being severely deficient. Z scores for weight showed normal range Z > -1 in 531 (24%) and the rest were deficient. Z -1 to −2 in 797 (36%), Z -2 to −3 in 686 (31%) and severely deficient in 202 (9%).Food frequency questionnaire and dietary recall in 2176 patients revealed that the standard diet taken by these children was low in protein (74%), potassium (43%), fiber (48%), calcium (55%), with low intake of fluids in 55% and high consumption of oxalate in 57%, sodium in 39%, purine in 42% and refined sugar in 41%. More than half (60%) of the population was taking less than the recommended calories.Urinary analysis: Urine analysis was undertaken in 2422. The mean urinary pH was 5.95±0.77. Fifty-five per cent had pH ≤ 5.5, 28% between 6-7 and 17% >7.0. The mean specific gravity was 1.018±0.06 with 48% having specific gravity of more than 1.020. Nitrite was positive in 33% and protein in 42%. Significant RBCs > 5 HPF were detected in 36%, WBCs > 10 HPF in 32% and crystals were seen in 54% of the urines. Crystal types were calcium oxalate in 45%, uric acid in 20%, ammonium hydrogen urate 5%, amorphous urates in 10% and struvite 7%. Xanthine crystals were seen in eight and cystine in eight patients.E. coli in 38%, proteus species 5%, enterobacter 7% and Klebsiella in 7%. In the renal failure group, cultures were positive in 245 (61%). Organisms isolated were E. coli in 38%, Klebsiella 15%, Pseudomonas 11%, enterobacter 8% and proteus in 8%. The rest of the positive had mixed bacterial growth and other organisms. Blood cultures were undertaken in 117 of these patients with sepsis. Organisms were isolated in 25, 10 patients had E. coli, six pseudomonas, six staph aureus coagulase and three had Klebsiella.Preoperative urine cultures: Overall cultures were positive in 1208 (46%) of the patients. Cultures were positive in 963 (43.5%) patients with normal renal function where common organisms isolated were Radiology and Imaging: Ultrasound (USG) KUB examination was done in all 2618 patients, intravenous urogram (IVU) was performed in 1133 patients with normal renal function, non-enhanced spiral CT scan of urinary tract in 39 cases and contrast enhanced spiral CT Scan in three cases.Distribution of stones in the urinary tract by imaging is given in Measurement of stone size in the upper tract (size of largest stone where multiple stones were present) showed that the mean size was 1.6±0.8 cm with a range of 0.2-6.0 cm. Of the 2618 patients evaluated, 38% had renal stones larger than 1.5 cm. The mean size of bladder stones was 2.1±1.2 cm with a range of 0.5-6.5 cm.Ultrasound findings were positive in 3234 renal units in the normal renal function group. Hydronephrosis was severe in 7%, moderate in 31% and mild in 25%. Cortical thickness was normal in 43%, mild reduction in 22%, moderate in 25% and severe reduction in 9% was observed. Congenital urological anamolies were found in 48 (2.2%) patients.Of the 402 in the renal failure group, 797 (99%) renal units showed positive findings while five renal units were absent. Size of the kidney was small in 161 (20%) renal units. Within this group of renal failure patients, 105 who were anuric, 93% of the renal units showed varying degree of hydronephrosis. Size of the kidney was normal in 75% and 84% of the renal units had normal or only mildly reduced cortical thickness while 80% had normal renal parenchymal echogenecity. In contrast, non-anurics of the renal failure group had normal sized kidneys in 67% and small in 24%. Cortex was moderately to severely reduced in 41% and there was markedly increased echogenecity in 57%. In all 17 (4%) of these patients had congenital urological anomalies.Blood Chemistry: Blood parameters were undertaken in 2391 patients. The majority of the patients had blood chemistry parameters within the normal range. The mean blood urea was 24.16 ± 8.3, creatinine 0.45±0.41, uric acid 3.99±2.1, calcium 10.25±4.9, phosphorus 5.7±2.25, magnesium 3.02±1.13, sodium 139.17±11.9, potassium 4.63±0.73, chloride 106.9±13.6, bicarbonate 21.85±4.1 and albumin 4.35±0.35. Borderline hypercalcemia, hyperuricemia and hyperphosphatemia was noted in 2%, 3% and 4% respectively.P=0.0001), hyperuricosuria (P=0.0001), hyperphosphaturia (P=0.009) and hyponatriuria (P=0.009) were significantly high in the ammonium hydrogen urate (AHU) group as compared to the calcium oxalate (CaOx) group while hypercalciuria (P=0.001) and hypernatriuria (P=0.001) were significantly high in the CaOx group as compared to the AHU group.Twenty-four hours urine study: Metabolic analysis was possible in 1892 patients. The mean values are given in Stone Analysis:Of the 2039 stones analyzed, 726 (36%) were composed purely of a single compound salt and 64% were mixed stones. Overall frequency of compounds in stones was AHU in 58%, calcium oxalate monohydrate (COM) in 63%, calcium oxalate dihydrate (COD) 20%, uric acid (UA) 6%, calcium phosphate apatite (CAP) 12% and struvite in 8%. Other stones in the kidney were cystine 1%, xanthine 1%, brushite 0.3%, protein 0.8% and 2,8 dihydroxy adenine 2, Newberyite 2 and whitlokite 4. Separate core and surface analysis was possible in 1274 renal and 198 bladder stones. Frequency of compounds in core of renal stones were AHU 64%, CaOx 41%, UA 3%, CAP 9% and struvite 5%. In the surface analysis, AHU reduced to 30% and CaOx increased to 72% while others were similar. Frequency of compounds in core of bladder stones was AHU 61%, CaOx 35%, UA 10%, CAP 7% and struvite 6%. Surface analysis again showed low AHU (37%), high CaOx (52%) and increased UA (16%), CAP (12%) and struvite (15%). Stratification of pure stones by age groups, A (≤5 years), B (6-10 years) and C (<10 years), showed differences in pattern of stones types. Group A, AHU 64%, CaOx 18%, Group B, AHU 19% and CaOx 61% while Group C, AHU 10% and CaOx 70% .Definitive management was undertaken after treatment of UTI with culture-specific antibiotics. In 402 patients with renal failure, initial management included hemodialysis in 180 (45%), peritoneal dialysis in 60 (15%), PCN in 104 (26%), JJ stenting in 45 (11%), while two patients reported so late that they died during resuscitation. Definitive surgical management included open surgery and minimally invasive techniques. Of the 2485 patients treated, open surgery was undertaken in 721 (29%), PCNL in 679 (27.5%), ESWL in 323 (13%), cystolithoclast in 475 (19%) and URS in 287 (15.5%). Following stone clearance patients were given dietary advice and medication according to risk factors and stone type. Hydration, Lemonade and polycitra at 3-4 mEq/day was given to all patients except the struvite stone formers. Polycitra was homemade and given free to all patients. Risk factors in stone formers, especially those with CaOx and AHU were treated according to the following protocol.Hyperoxalurics: Oxalate levels of <2 mg/kg/24h were advised dietary restriction of oxalate-rich foods, normal recommended calcium intake and those with > 2 mg/kg/24h were given pyridoxine 25–50 mg/day according to age along with dietary restrictions.Hyperuricosurics: Dietary restriction of purine-rich foods and allupurinol in a dose of 10 mg/kg/day.Hypercalciurics: Dietary restriction of excessive calcium and sodium. Thiazides at 1mg/kg/day especially with calcium renal leak.Hypocalciurics: Milk supplements and restriction of oxalate-rich foods.Cystine stone formers: They were advised dietary protein and sodium restriction and were given polycitra at 3-4mEq/kg/day to maintain pH > 7.5. Patients were advised to keep a close check of urine pH in every urine void with litmus paper provided to them.Calcium phosphate stone formers: They were advised dietary restriction of phosphate-rich foods and calcium restriction and increase of fiber in their diet.Uric acid stone formers: Patients were advised alkalization with 3-4 mEq/kg/day of polycitra to keep a urinary pH of ≥ 6.5, allupurinol 10 mg/kg/day and purine restriction where indicated.Xanthine and 2–8 dihydroxyadenine stone formers: They were advised hydration and alkalization with polycitra and regular check of urinary pH by litmus paper.Struvite stones: Patients with struvite stones were managed by complete stone removal including fragments. Where indicated anatomical abnormalities were corrected and long-term culture-specific antibiotics were given usually for six weeks and in some cases up to three months.P <0.0001), hyperuricosuria from 26% to 6% (P < 0.0001), hypocalciuria from 20% to 5% (P < 0.0001), hypercalciuria from 26% to 5% (P <0.0001), hyperoxaluria from 43% to 15% (P <0.0001), hyponatriuria from 38% to 11% (P <0.0001), hypokaluria from 47% to 8% (P <0.0001) and hypocitraturia from 87% to 10% (P <0.0001). In 2216 patients with normal renal function recurrence was noted in 25 (1.15%) in the period of follow-up. Of these, eight had cystine stones, three xanthine, eight struvite, one uric acid and five patients had CaOx stones.Follow-up metabolic analysis was undertaken in 1575 patients. Overall hypovolumia reduced from 31% to 5%  is useful in complex cases, where other imagining modalities are not helpful.E. coli. Moreover, E. coli was also predominant in patients with sepsis. It appears that UTI in our patients is secondary to stones and obstruction caused by stasis and delay in treatment. Low frequency of struvite stones (5-12%) is also reported by others in our region[Routine urine analysis by dipstick and microscopy is of value where nitrite positivity and pus cells were helpful findings for further culture tests. Presence of stone-specific crystals e.g. struvite, cystine, xanthine and AHU identify stone type. Large stone burden in half of the patients with upper and lower tract stones together with neglect predisposing them to infection. High rate of urine culture positivity is comparable to others, however,ur region15 which ur region13Anthropometric findings were indicative of malnutrition as the majority of the patients were deficit in height and weight by Z scores and the majority were taking less than recommended calories.7 The dieCollection of 24h urine is a challenge, especially in younger children yet its analysis identified risk factors in the majority of the patients. Hypocitraturia was the commonest finding as reported by others in the region. This is Stone composition provided key information where core and surface analysis was possible. The core was composed of AHU in 34% of the pure renal stones. This increased to 66% in children less than five years of age. In contrast, core was composed of CaOx in 70% of children more than 10 years of age. The pattern of stone composition in older children was similar to that reported from developed countries where CaOx predominates.13 Howeve147The hallmark of stone management is complete stone removal and prevention of recurrence. In our patients it is equally important to treat infections due to stones and to preserve renal function as many patients present late with renal failure. This requires a multidisciplinary approach, all under one roof comprising intensivist, radiologist, pathologist, nephrologist, anesthesiologist and urologist. Such an approach was beneficial, especially in the oligo-anuric group who presented with acutely obstructed kidneys with normal cortex. The majority of these cases showed complete recovery of renal function. Although the majority of the patients were managed by minimally invasive techniques, a quarter needed open surgery due to large stone burden, impacted stones and compromised kidneys. The value of extensive protocol in these children who are at high risk can be appreciated from the finding that we were able to identify the risk factors in 90% of the patients. Dietary and pharmacological interventions enabled us to reduce risk factors in 2/3 of our patients. Low recurrence rates observed in our series as compared to others of up to 50%, where no medical intervention or follow-up was undertaken, suggest 18Pediatric stone formers present with vague urological symptoms where previous history gives an index of suspicion. Ultrasound is diagnostic in the majority of the cases and gives pertinent information on site, size of stone and anatomy of the renal units. On the backdrop of malnutrition, chronic dehydration and a diet poor in proteins and rich in oxalates, lead to formation of AHU stones which constitute up to 64% of stones in children <5 years of age, who are most likely to suffer from these risk factors. Calcium oxalate lithogenesis in these children is a byproduct as a result of AHU nidus while it is the main disease in older children where hyperoxaluria, hypocalciuria and dietary deficiency of citrates and dehydration may well be the main risk factors. Both AHU and CaOx stones thus seem preventable where dietary modifications and diarrheal disease may play a pivotal role. In our experience true assessment of risk involves a trio of evaluation to include diet, 24h urinary analysis and composition of stones. These can identify the risks in the majority of the children with stones. Dietary and medical management can help reduce risk factors by two-thirds resulting in recurrence rates of about 1%. A systematic evaluation protocol in the stone clinic will help in management strategies and is practical and affordable from the developing world's perspective.


A population-based case-control study of leukaemia and residential proximity to electricity supply equipment has been carried out in south-east England. A total of 771 leukaemias was studied, matched for age, sex, year of diagnosis and district of residence to 1,432 controls registered with a solid tumour excluding lymphoma; 231 general population controls aged 18 and over from one part of the study area were also used. The potential for residential exposure to power frequency magnetic fields from power-lines and transformer substations was assessed indirectly from the distance, type and loading of the equipment near each subject's residence. Only 0.6% of subjects lived within 100 m of an overhead power-line, and the risk of leukaemia relative to cancer controls for residence within 100 m was 1.45  0.54-3.88); within 50 m the relative risk was 2.0 but with a wider confidence interval (95% CI 0.4-9.0). Over 40% of subjects lived within 100 m of a substation, for which the relative risk of leukaemia was 0.99. Residence within 25 m carried a risk of 1.3 (95% CI 0.8-2.0). Weighted exposure indices incorporating measures of the current load carried by the substations did not materially alter these risks estimates. For persons aged less than 18 the relative risk of leukaemia from residence within 50 m of a substation was higher than in adults .