Chlamydia trachomatis (C. trachomatis), an obligate intracellular bacterium, is the commonest infectious bacterial agent of sexual transmission throughout the world. It has been shown that the presence of this bacteria in the cervix represents a risk regarding HPV persistence and, thereafter, in developing cervical cancer (CC). Prevalence rates may vary from 2% to 17% in asymptomatic females, depending on the population being analysed. This study reports the identification of C. trachomatis in a cohort of 219 HPV-infected Colombian females.C. trachomatis infection frequency was determined during each of the study’s follow-up visits; it was detected by amplifying the cryptic plasmid sequence by polymerase chain reaction (PCR) using two sets of primers: KL5/KL6 and KL1/KL2.Infection was defined as a positive PCR result using either set of primers at any time during the study. Cox proportional risk models were used for evaluating the association between the appearance of infection and a group of independent variables.C. trachomatis infection frequency was 28% (n = 61). Most females infected by C. trachomatis were infected by multiple types of HPV (77.42%), greater prevalence occurring in females infected with HPV-16 (19.18%), followed by HPV-58 (17.81%). It was observed that females having had the most sexual partners (HR = 6.44: 1.59–26.05 95%CI) or infection with multiple types of HPV (HR = 2.85: 1.22–6.63 95%CI) had the greatest risk of developing C. trachomatis.Base line C. trachomatis /HPV coinfection in different population groups of Colombian females and contributes towards understanding the natural history of C. trachomatis infection.The study provides data regarding the epidemiology of  Chlamydia trachomatis (C. trachomatis) is an obligate intracellular bacterium which can infect both ocular and genital tissues. Infection by C. trachomatis causes chronic inflammation damaged epithelial tissue and pelvic inflammatory disease (PID). Due to being obligate and intracellular, the pathogen persists in a host after an immune response has been developed, meaning that it could produce chronic disease, causing damage to tissue, resistance to apoptosis and affecting host ability to clear other STI infections [fections , 2.C. trachomatis is the commonest infectious bacterial agent of sexual transmission throughout the world [C. trachomatis in 2005 and 101 million new cases of C. trachomatis occur annually around the world [C. trachomatis prevalence has been reported as being 1.4% for males and 1.6% for females in people aged 18–44 years old, the highest rates occurring in subjects aged 18 to 29 years old: 2.5% for males and 3.2% for females. Its prevalence in sexually-transmitted infection (STI) detection centres has been seen to rise to 15% [he world , 4. The he world . C. trace to 15% .C. trachomatis infection prevalence and determinants in Colombia have not been described completely. Some data have been reported by the Colombian Ministry of Health and Social Protection indicating that 1,538, 1,525 and 1,313 people were diagnosed as being infected by C. trachomatis in 2009, 2010 and 2011, respectively. It has also been indicated that this is the most prevalent STI in people aged 15 to 49 years-old [C. trachomatis infection, its long-term persistence and its ability to induce chronic inflammation and metaplasia has led to this bacteria being considered a potential cofactor in high-risk (HR) human papilloma virus (HPV) infection since it could promote the virus’ persistence and/or potentiate its oncogenicity [The asymptomatic nature of genicity . Besidesgenicity .C. trachomatis) [HR-HPV types are considered the main aetiological agents of cervical neoplasia (CN) , howeverhomatis) .C. trachomatis coinfection frequency must be estimated regarding females with/without cervical lesions [C. trachomatis when there is coinfection with HPV has been poorly evaluated in Colombia to date [C. trachomatis frequency in a population of HPV-infected females living in 3 cities in Colombia . This is the first study which has evaluated a cohort which was completely infected with HPV at the start; the aim was to determine C. trachomatis infection incidence and the risk factors associated with HPV coinfection.The importance of such infection in terms of public health means that HPV and  lesions  associat to date . This stThe population studied consisted of 219 females whose ages ranged from 17–71 years old. A previous study has described how the cohort was assembled for identifying HPV, involving 3 follow-ups every 6 months (± 3 months) .The females in the study were living in 3 cities in Colombia: Bogotá, the capital city, Chaparral in the Tolima department and Girardot in the Cundinamarca department, where intrinsic characteristics have been identified in previous studies regarding the risk of contracting HPV infection . ChaparrC. trachomatis was determined from samples taken from the 219 HPV-infected females at the start of the follow-up and thereafter during each visit whilst the study lasted.The females involved in the study carried out by the Fundación Instituto de Inmunología de Colombia (FIDIC) voluntarily decided to participate in sampling between April 2007 and March 2010; they signed an informed consent form which explained the risk factors associated with the exams and sample taking. A parent or guardian/teacher had to sign for girls aged less than 18 years old. All the procedures were approved by the following hospitals’ ethics’ committees: Hospital de Engativá (Bogotá population), Hospital San Juan Bautista  and Nuevo Hospital San Rafael (Girardot). Biological material was obtained from cervical smear samples collected after cytology and stored at -20°C. The samples were processed and DNA extracted, according to information previously published by our group .C. trachomatis in samples from HPV-infected females. Two sets of primers previously reported in the literature were used; KL5/KL6 [Polymerase chain reaction (PCR) amplification of a sequence from the microorganism’s cryptic plasmid was used for detecting  KL5/KL6 , 17 ampl KL5/KL6 , 18, 19 C. trachomatis detection [C. trachomatis ATCC UW-36/Cx strain (ATCC VR-886D) was used as positive control for each amplification and DNAse-free water as reagent control. The PCR for each set of primers was done at 20 μL final volume, using 3 μL of sample, with approximately 900 ng of DNA.Amplification conditions were chosen and adjusted according to the methodologies described for etection , 18, 19.2, 1.25mM each desoxinucleotide triphosphate (dNTP), 20 pmol of each primer and 1.25 μL of Taq DNA polymerase (5U/μL). This set of primers’ thermal profile involved an initial cycle at 94°C for 5 minutes, followed by 35 cycles of 1 minute at 93°C, 1 min at 56.8°C, 1 min at 72°C and a final extension step at 72°C for 10 minutes.Reaction conditions for KL5 and KL6 were: 1X concentration Bioline buffer , 3mM MgCl2, 1.25mM each desoxinucleotide triphosphate (dNTP), 20 pmol of each primer and 1.25 μL of Taq DNA polymerase (5U/μL) (Bioline). This set of primers’ thermal profile involved an initial cycle at 94°C for 5 minutes, followed by 35 cycles of 1 minute at 93°C, 1 min at 55°C, 1 min at 72°C and a final extension step at 72°C for 10 minutes.Reaction conditions for KL1 and KL2 were: Bioline buffer  at 1X concentration, 3mM MgClBovine serum albumin (BSA) was added to the molecular biology grade water used in the PCR reactions at 0.8 μg/μL concentration; this was added to increase PCR efficiency as described earlier .C. trachomatis infection frequency was determined during each follow-up visit of the study. Means and their corresponding measures of dispersion (standard deviation) were used for describing continuous variables. Categorical variables were expressed in terms of frequencies and percentages.2 (χ2) and Fisher’s exact tests, depending on contingency table characteristics.The association between the presence of infection and a group of categorical variables was evaluated; these were: smoking, city, ethnicity, age on first sexual relationship, number of sexual partners, family planning method, presence of sexually-transmitted infection (STI), number of children, history of abortions, coinfection with HR-HPV, HPV16, HPV18, HPV31, HPV45, HPV33, HPV58, the amount of HPV infecting types, cytology , colposcopy , using ChiC. trachomatis infection was defined as a positive PCR result using either set of primers at any time during the study. Clearance was defined as C. trachomatis not being detected by both sets of primers following a positive finding during the previous visit. Persistence was defined as the presence of infection in two consecutive visits. Coinfection was defined as the simultaneous presence of C. trachomatis and HPV infection whilst the coexistence of two or more types of HPV was defined as multiple infection; such definitions were used according to that established in previous studies [ studies –23.C. trachomatis when the cohort study began  whilst the second subpopulation involved females who were infected from the start . Follow-up times were used for estimating Kaplan-Meier survival functions for each outcome (infection or clearance).Two subpopulations were defined for the cohort study; the first involved patients who were not infected by C. trachomatis) and clearance rates (for those who were infected at the beginning) were estimated according to the information obtained. Time was calculated in terms of months elapsed since the beginning of follow-up until the event in question (infection or clearance). Cases where no event occurred and follow-up had ended were handled as right censoring for survival analysis.Infection  and coinfection with HR-HPV. The beginning of risk was assumed to be when the cohort began without infection and with follow-up until the presence of an infection event, or the end of the study considered a closed case. The strength of association between the independent variables and the risk of having infection was quantified by using a hazard ratio (HR) estimator, i.e. the ratio of hazard rates for the independent variables’ different levels.The hypothesis tests involved using 5% significance (p ≤ 0.05), 95% confidence interval (CI) for the estimator and two-tail hypothesis. STATA 12 software was used for all statistical analysis.C. trachomatis infection result during visit 0 (base line visit) was taken as starting point for further analysis; C. trachomatis was positively identified in 57 females during visit 0, whilst 157 did not have C. trachomatis during the same visit.Two hundred and nineteen cervical samples from females who stared the cohort infected by HR-HPV  were analysed; these females were followed-up every 6 (±3) months. All the females made a minimum of 3 visits (n = 216); however, some of them (n = 49) made 5 visits. A positive or negative C. trachomatis at the start of the cohort lived in Bogotá and the remaining 59.68% (n = 37) in a population classed as “different to Bogota”. C. trachomatis infection state. The highest detection rate was obtained during follow-up visit 2 where the highest level of C. trachomatis infection was observed  of the females infected by observed .C. trachomatis infection was much greater than that for those having just a single HPV infection (22.58%). Regarding C. trachomatis coinfection and different types of HR-HPV, it was found that type 16 was present in most females in the cohort (51.59%) compared to the total population, followed by types 18 (40.63%), 45 (36.98%), 58 (27.85%), 31 (23.28%) and 33 (5.47%). The greatest C. trachomatis frequency rate for multiple HPV infection was found in HR-HPV type 16 (19.18%) followed by type 58 (17.81%). A statistically significant difference was observed between populations infected by C. trachomatis and those without infection regarding females infected by HR-HPV 58 and 45.The percentage of females infected by multiple types of HPV (77.42%) proving positive for C. trachomatis -free during total follow-up time (around 2 years). Infection rate was 5.1 per 100 people during one month (4.27–6.14 95%CI). C. trachomatis infection. C. trachomatis infection in time.For females who began the study without infection, the total time contributed towards the study cohort was 2,281 months; 74.52% (n = 117) of them became infected, whilst 25.47% (n = 40) remained Females who began with infection contributed 587 months at risk to the study cohort, infection rate being 9.7 per 100 people in a month (7.48–12.58 95%CI); 8.06% (n = 5) of the females who started infected did not clear the infection during the time the study lasted.C. trachomatis infection frequency was 28% (n = 61). There was 85% (n = 52) C. trachomatis identification by the KL1/KL2 and 29% (n = 18) with KL5/KL6 set of primers in base line data. The detection limit for each set of primers was calculated, the results showing that KL1/KL2 detected lower amounts of C. trachomatis DNA (48.2 μg/μL) compared to the KL5/KL6 set of primers (57.6 μg/μL).Base line C. trachomatis infection were analysed in this study, such as race, smoking, age on first sexual relationship, the family planning method used, the number of sexual partners, age, the number of children, the relationship of C. trachomatis coinfection with multiple HPV infection and the presence or absence of other STI. Amongst these variables, it was observed that females having had the most sexual partners (HR = 6.44: 1.59–26.05 95%CI) or infection with multiple types of HPV (HR = 2.85: 1.22–6.63 95%CI) had the greatest risk of developing C. trachomatis infection  [C. trachomatis infection rates in the only Colombian study to date were estimated in a general population of women.This study involved a group of 219 females whose ages ranged from 17–71 years old. The estimated base line ly (17%)  and Argely (17%) ; howeverC. trachomatis identification, thereby increasing the chance of finding positive samples. Previous studies have reported the individual use of the primer sets tested here in samples from HPV-infected women, showing 13% frequency for KL5/KL6 and 34.9% for KL1/KL2 [Identifying greater prevalence than that reported in other studies relied on two significant factors. This cohort represented a population at risk since all the females were infected by HPV when the cohort started, meaning that this population was probably engaging in behaviour leading to the risk of acquiring an STI . The sec KL1/KL2 .C. trachomatis infection, an increased number of sexual partners was found, thus agreeing with previous reports describing a similar association not only with C. trachomatis, but with almost all STI [Regarding the risk factors associated with acquiring  all STI –30. The  all STI , 31–33.C. trachomatis infection favours the entry and persistence of multiple HR-HPV types which leads to viral integration, apoptosis inhibition, overexpression of the E6 / E7 oncogenes and cellular transformation [C. trachomatis pathogeny and the tissue damage produced in chronic infections, this epithelium could become affected by various types of HPV virus, leading to multiple infections, as observed in this study. This has been reported in a previous study involving multiple detection of HPV-16 and -18 genotypes [Another relevant factor found was infection by multiple HR-HPV types, similar to what has been described in other Latin American countries , 27, 34.ormation . Bearingenotypes .C. trachomatis coinfection with different types of HR-HPV, it was found that types like HPV-16 and -18 occurred most frequently, similar to that reported in a population of female aborigines in the north of Argentina [Regarding rgentina ; howeverrgentina . Such daC. trachomatis coinfection with HPV-HR in the cohort being studied involved type 16. It has been reported in the literature that C. trachomatis infection improves Ki67 protein expression, this being a marker for cervical epithelium cell proliferation; the same is true for HPV infection, especially that including HPV-16 [C. trachomatis infection increased HPV-16 expression in CIN I, suggesting that it could modify the activity of this type of virus; it has also been confirmed that C. trachomatis infection has increased EGFR and TGF-alpha expression and this could explain distinct variants of the cervical carcinogenesis mechanism [The most common g HPV-16 . It has echanism .C. trachomatis infection frequency in our study which might have been related to a pattern of multiple HPV infection distribution in our population, since a previous report has shown that HPV-58 and -45 are usually present in multiple infections [It is worth mentioning that HR-HPV 58-infected women had the second highest fections .C. trachomatis six months after the study began and that half the population had become infected after one year’s follow-up. On the other hand, females who were infected at the start of the cohort required about six months to a year for clearing the infection. This result agreed with a previous study carried out in Bogotá [C. trachomatis infected women who did not receive therapy resolved the infection in 1 year. No particular variation in infection clearance time was found here when comparing the three geographical populations studied.It could be seen that around a quarter of the HPV-infected females in this cohort had become infected by n Bogotá  (one of C. trachomatis infected women in Amsterdam had a person/year spontaneous clearance rate of 44.7%. However, the pertinent study stated that genital C. trachomatis infection duration in the absence of treatment had not been completely elucidated, but available long-term studies suggest that a typical untreated C. trachomatis infection can last a year or longer before clearance [Data for asymptomatic learance , 37.C. trachomatis infection; this has been supported by studies in animal models concluding that estradiol reduces the susceptibility to intrauterine C. trachomatis infection in rats [C. trachomatis infection clearance rate [The present study found that females in the cohort using a hormone-based family planning method had less risk of developing  in rats . Other ance rate .C. trachomatis in a population of females who were not infected by this virus for statistically correlating frequency in both groups, thereby contributing towards assessing C. trachomatis infection rates in the Colombian population. Determining and analysing the types of C. trachomatis in patients having cytological findings would establish whether the relationship of both agents came from mutual potentiation rather than the fact that they share a common transmission route.A weakness of this study of a cohort of HPV-infected females was that it lacked parallel screening involving C. trachomatis/HPV coinfection in different population groups of Colombian females. Having had more sexual partners and infection by multiple types of HPV is associated with a greater risk of becoming infected by C. trachomatis. Using hormonal contraceptives was a factor for the cohort being studied, as significant importance was found regarding an association with lower risk of becoming infected by C. trachomatis. This paper contributes towards understanding the natural history of C. trachomatis infection.The study provides data regarding the epidemiology of


P = 0.01) and MGMT status . The most common treatment-related adverse events were fatigue, proteinuria, hypophonia, hypertension, thrombocytopenia, anemia, and neutropenia. In conclusion, combination of BEV with FTM is well tolerated and may derive some clinical benefits in recurrent GBM patients. Higher KPS and MGMT promoter hypermethylation were suggested to be associated with prolonged survival.The aim of this study was to assess the activity and safety of bevacizumab (BEV) and fotemustine (FTM) for the treatment of recurrent glioblastoma multiforme (GBM) patients and explore the potential prognostic parameters on survival. This study retrospectively analyzed all patients with GBM who were treated with at least one cycle of BEV and FTM from July 2010 to October 2012. A total of 176 patients with recurrent GBM were enrolled. The response rate and disease control rate were 46.6% and 90.9%, respectively. A 6-month PFS rate of 33.3% (95% CI: 26.5%–40.3%) and a median PFS of 5.0 (95% CI: 2.4–7.5) months were observed. The median OS was 8.0 (95% CI: 6.7–9.2) months. Multivariate analysis showed that risk factors with a significant influence on the PFS of all patients were Karnofsky Performance Status (KPS) (≥70 versus <70, HR = 0.53, 95% CI: 0.39–0.73, and  Glioblastoma multiforme (GBM) is the most common malignant brain tumor in adults and accounts for 17% of intracranial tumors . Its aggIt is known that GBM is one of the most vascularized human tumors and that GBM cells produce proangiogenic factors, including VEGF. VEGF binds with its corresponding tyrosine kinase receptors, activating a downstream signal that results in the development of angiogenesis, increased vascular permeability, and lymphangiogenesis. Bevacizumab (BEV), a humanized monoclonal antibody against VEGF, alone or associated with chemotherapy or targeted medicines, has reported higher response rates and prolongation of median and 6-month progression-free survival compared to controls with non-bevacizumab treatments –7. It waThe aim of this retrospective study was to evaluate the activity and safety of BEV and FTM for the treatment of recurrent GBM patients and explore the potential prognostic parameters on survival.This study was a monocentric retrospective research conducted at Department of Neurology, Zhongshan Hospital, Xiamen University. All patients gave their written informed consent after being informed of the purpose and investigational nature of the study. The principles of the World Medical Association Declaration of Helsinki and Good Clinical Practice Guidelines were strictly followed.μL; platelets count ≥ 100,000 μL. Patients were excluded as follows: (1) evidence of hemorrhage on the baseline MRI or previous treatment including either BEV or FTM; (2) pregnancy or nursing; (3) uncontrolled hypertension; (4) cardiac arrhythmias; (5) history of congestive heart failure or stroke; (6) active infection requiring intravenous antibiotics; (7) urine protein : creatinine ratio > 1; (8) psychiatric disorders; (9) other conditions that would make the treatment unsafe.Inclusion criteria for the study were as follows: (1) age ≥ 18 years; (2) histological diagnosis of glioblastoma at original surgery or at reoperation; (3) first progression after radiotherapy and concomitant/adjuvant temozolomide; (4) adequate hematological, liver, and renal function: hematocrit > 29%; absolute neutrophil count (ANC) ≥ 1,000 2 intravenously on days 1 and day 8, followed after an interval of 3 weeks by a maintenance phase with BEV at 10 mg/kg and FTM at 75 mg/m2 every 3 weeks until tumor progression, withdrawal of the patient, or unacceptable toxicity. Ten minutes before each infusion of FTM, a 5-HT3 receptor antagonist was administered for antiemetic prophylaxis. Antiepileptic drugs were given during the study period as medically indicated. Glucocorticoids were used to the dose necessary for neurologic stability. FTM administration was held in case of grade 3-4 thrombocytopenia and/or neutropenia and grade 3-4 nonhematological toxicity except for nausea/vomiting. At recovery, treatment was resumed with a 25% dose reduction. BEV was discontinued for uncontrollable hypertension, grade 2 or greater hemorrhage, arterial thrombosis, severe proteinuria, or congestive heart failure. BEV was held until other related grade 3 events resolved to grade ≤1.Eligible patients were treated with a combination of BEV and FTM. The treatment consisted of an induction phase with BEV at 10 mg/kg intravenously on days 1 and 15 and FTM at 75 mg/mA full medical history was determined at treatment initiation and patients were examined for physical and neurological status, vital signs, and Karnofsky Performance Status (KPS) every 4 weeks. MRI scans were undertaken to evaluate tumor size and location every 8 weeks.Tumor response was evaluated according to the MacDonald criteria every two treatment cycles or onset of progressive disease, considering MRI measurements of contrast-enhancing tumor size and recording of the largest cross-sectional area of the tumor and patient neurological status. Tumor response was codified as complete response, partial response, stable disease, and progressive disease when compared to best overall response scan. Progression-free survival (PFS) and overall survival (OS) were also recorded. PFS was defined as the time from the first administration of BEV and FTM to documented progression or death. OS was defined as the time from the first administration of BEV and FTM to date of death from any cause. Adverse events were graded according to NCI-CTCAE, version 3.0, criteria.μL (4.4 M sodium bisulfite and 20 mM hydroquinone) for five hours at 55°C and then purified. The methylation-specific PCR was performed in a two-step approach.Genomic DNA was isolated from one paraffin section of glioblastoma tissue, denaturated with sodium hydroxide, and subjected to bisulfite treatment in a volume of 350 P values <0.05. All statistical analyses were performed with the SPSS statistical software program package .All categorical variables are summarized and expressed as proportions. OS and PFS were estimated using the Kaplan-Meier method and the 95% confidence interval (95% CI) for median survival was estimated by the Brookmeyer-Crowley method. Moreover, subset analyses were conducted, using the Cox proportional hazard model, to identify factors that influenced OS and PFS. Statistical significance was defined as A total of 176 consecutive patients, including 111 men and 65 women, with recurrent GBM admitted to Department of Neurology, Zhongshan Hospital, Xiamen University, between July 2010 and October 2012, were enrolled. The patient characteristics are summarized in All follow-up assessments were completed by December 2013. Outcomes could be confirmed in all patients; no patient was lost to follow-up. At the end of the study, 2 patients were free of tumor progression and alive. The median follow-up for all patients was 9.5 months (95% CI 7.5–10.5).All patients were evaluable for response rate. 3 cases of complete response were observed; 79 patients achieved partial response while 78 patients had disease stabilization, for a response rate of 46.6% and a disease control rate of 90.9%. The disease progressed in 16 patients.P < 0.01). PFS rates at 6 months and 12 months were 33.3% (95% CI: 26.5%–40.3%) and 10.7% (95% CI: 6.7%–15.8%) (P < 0.01).Median OS was 8.0 (95% CI: 6.7–9.2) months. At 6 and 12 months, 65.3% (95% CI: 57.7%–71.9%) and 22.0% (95% CI: 16.1%–28.4%) of patients were alive, respectively. OS differed with regard to response: 9.0 (95% CI: 8.3–9.9) months for responders and 6.5 (95% CI: 5.5–7.3) months for nonresponders (%–15.8%) . Median P < 0.01) and MGMT status  (P = 0.01) and MGMT status  were prognostic factors for PFS.All potential prognostic variables were analyzed to establish their effect on progression-free and overall survival rates.  = 0.03) . Univari = 0.03) . The med = 0.03) . On multP = 0.01; multivariate analysis, ≥70 versus <70, HR = 0.58, 95% CI: 0.39–0.76, and P = 0.01) was the only prognostic factor to significantly impact OS  and a lower disease control rate (89%) . In our A difference in survival among patients with GBM has been found to depend on KPS and MGMT status. Maintenance of functional independence (KPS ≥ 70) is supposed as important component of clinical activity and treatment compliance for patients with a brain tumor, particularly those with recurrent GBM , 22. In The combination of BEV and FTM used herein is well tolerated. Most frequent grade 3-4 toxicities were primarily related to chemotherapy. BEV-related toxicities were consistent with those reported in other trials , 35. In Preliminary results of the Dutch phase II , randomized trial on firstly recurrent GBMs comparing BEV plus lomustine versus either lomustine or BEV alone, showed a better outcome in terms of 6-month PFS and OS for the combination : a randomised controlled phase 2 trial). However, Soffietti et al.'s outcomes were unable to demonstrate a superiority of the combination of BEV and FTM over either BEV or FTM alone as historical control. Future studies should investigate whether a clinical benefit from the combination could emerge by employing different doses and schedules of BEV and FTM.It should be noted that our study has some limitations. Even though Macdonald criteria were widely used to assess response to treatment of glioblastoma since published in 1990, they have been largely superseded by the RANO criteria which have become the mainstay of assessment (Monitoring Radiographic Brain Tumor Progression). Compared with RANO, the use of Macdonald criteria might yield a longer PFS because of later identification of progression. Furthermore, the sample size was small, and the physician that evaluated the MRI scans was not blind to clinical data.According to the findings of the present study and review of the literature, GBM is a highly aggressive tumor which tends to have early relapse and short-term survival. This study shows that the combination of BEV with FTM is well tolerated and may derive some clinical benefits in recurrent GBM patients. Higher KPS and MGMT promoter hypermethylation were suggested to be associated with prolonged survival.


Podarcis muralis, on Jersey  and in the Chausey archipelago. We sequenced a fragment of the mitochondrial cytochrome b gene in 200 individuals of P. muralis to infer the phylogeography of the island populations using Bayesian approaches. We also genotyped 484 individuals from 21 populations at 10 polymorphic microsatellite loci to evaluate the genetic structure and diversity of island and mainland (Western France) populations. We detected four unique haplotypes in the island populations that formed a sub-clade within the Western France clade. There was a significant reduction in genetic diversity  of the island populations in relation to the mainland. The small fragmented island populations at the northern range margin of the common wall lizard distribution are most likely native, with genetic differentiation reflecting isolation following sea level increase approximately 7000 BP. Genetic diversity is lower on islands than in marginal populations on the mainland, potentially as a result of early founder effects or long-term isolation. The combination of restriction to specific localities and an inability to expand their range into adjacent suitable locations might make the island populations more vulnerable to extinction.Populations at range limits are often characterized by lower genetic diversity, increased genetic isolation and differentiation relative to populations at the core of geographical ranges. Furthermore, it is increasingly recognized that populations situated at range limits might be the result of human introductions rather than natural dispersal. It is therefore important to document the origin and genetic diversity of marginal populations to establish conservation priorities. In this study, we investigate the phylogeography and genetic structure of peripheral populations of the common European wall lizard,  There is a growing interest in the patterns and processes associated with geographical variation in population genetic structure across species’ ranges since these often shift, expand and contract over time –4. HistoPelophylax lessonae) in Britain. Initially considered to be present solely as a result of human introductions the native status of pool frogs was confirmed just in time to witness its extinction  and Hpod [3′-GGTGGAATGGGATTTTGTCTG-5′] ,26–28. AGeneious 6.1.7 [cyt-b region to amino acid sequences, to verify that no premature stop codons disrupted the reading frame. Unique sequences were submitted to GenBank under the accession numbers KP118978-KP118990.Sequencing reactions were carried out with BIGDye Terminator v3.1 Ready Reaction kit  in both directions. Products were precipitated in isopropanol and analysed on an ABI 3130 automated capillary sequencer . Mitochondrial DNA sequences from both directions were corrected by eye and aligned to obtain a consensus sequence. Accepted sequences were then aligned using MAFFT  implemenet al. [et al.[2O. PCR conditions were as follows: 15min of initialization step at 95oC, 26 cycles of 30sec at 94 oC, 90sec at 57 oC (for multiplex 1 and 2) or 55 oC (for multiplex 3) and 1min at 72oC and a final extension step of 20min at 60oC. The 5’-end of each forward primer was labeled with a fluorescent dye either 6-FAM, HEX or NED. PCR products were run with an internal ladder (red ROX-500), on an ABI 3130 genetic analyser (Applied Biosystems Inc.) We scored alleles in Geneious 6.1.7 and any ambiguous peaks were repeated to confirm genotype.To infer the genetic structure and diversity of our populations we genotyped 484 individuals at 10 polymorphic microsatellite loci; four described by Richard et al.  and six . [et al. (Table AP. siculus (AY185095) [P. liolepis (JQ403296) [P. melisellensis (AY185097) [MrBayes [Mega 5.2 . The BI analysis was run with four chains of 1,000,000 generations and sampling every 100 trees. We discarded (burn-in-length) the first 10% of the trees after checking for convergence of the chains and the posterior probability branch support was estimated from the 50% majority-rule consensus tree.We used the phylogenetic tree approach to assign haplotypes to known lineages by combining our sequences with 68 sequences (of varying lengths), obtained from GenBank, across the native distribution of the species (see Table B in Y185095) , P. liolQ403296)  and P. mY185097)  were use[MrBayes  under thMega 5.2 40. ThTo investigate evolutionary relationships of our sequences, we constructed a parsimonious phylogenetic network using a median—joining algorithm in Network v.4.6.12 . The meticrochecker V.2.2.3 [O, HE) were calculated with Genalex 6.5 [R) with Fstat v.2.9.3 [IS) and deviations from Hardy-Weinberg equilibrium were also evaluated at the 0.05 nominal level for multiple tests using sequential Bonferroni corrections in Fstat v.2.9.3 [O, HE, AR in island versus mainland populations with a Welch Two Sample t-test and evaluated the correlation between expected heterozygosity and latitude with a Spearman’s rank correlation test in R [We checked the microsatellite data in M V.2.2.3  for nullalex 6.5  and alle v.2.9.3 ,45. Inbr v.2.9.3 ,45. We cest in R .Structure v.2.3.4 [6 iterations from K = 1 through 5. Runs for each K were replicated 10 times and the true K was determined according to the method described by Evanno et al [Structure Harvester v.0.6.93 [Arlequin 3.5.1.3 [ST values and visualized with a Principle Coordinate Analysis (PCoA) in Genalex 6.5 [To infer population structure, we implemented a Bayesian analysis in  v.2.3.4  using th v.2.3.4 . The simno et al  in the ov.0.6.93 . We testv.0.6.93 ) in Arle 3.5.1.3 . Populatalex 6.5 .Analysis of mtDNA sequences of 192 individuals revealed 13 unique haplotypes all nested within the Western France Clade . The mosp<0.05) in the island populations of Jersey and Chausey than in mainland France populations  between latitude and expected heterozygosity  and multiplex three (3) was developed by Richard et al. (2012). Table B, List of sequence data used in the phylogenetic analysis. Information on sampling location, GenBank accession numbers and the reference study. Table C, Historical information on the island populations of the wall lizard. Table D, Table of null alleles per population per locus. Bold values indicated significant deviation from Hardy-Weinberg equilibrium (p<0.05). Table E, Matrix of pairwise FST values. Figure A, Plot of Delta K (ΔΚ). Calculated as in Evanno et al. (2005) from K = 2 to K = 4. Highest Delta K for K = 3. Figure B, Plots of genetic diversity indexes between island (group 1) and mainland populations (group 2). Genetic diversity is expressed as HO, HE and AR. Differences in the mean numbers were compared with a Welch Two Sample t-test.Multiplexes one (1) and two (2) were developed by Heathcote (DOCX)Click here for additional data file.


To evaluate the effectiveness of Spot photoscreener in detecting amblyopia risk factors meeting 2013 the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) criteria in Chinese preschool and school-age children.One hundred and fifty-five children (310 eyes), aged between 4 to 7 years (5.74 ± 1.2 years) underwent complete ophthalmologic examination, photoscreening, and cycloplegic retinoscopy refraction. The agreement of the results obtained with the photoscreening and retinoscopy was evaluated by linear regression and Bland-Altman plots. The sensitivity and specificity of detecting amblyopia risk factors were calculated based on the AAPOS 2013 guidelines. The overall effectiveness of detecting amblyopia risk factors was analyzed with Receiver Operating Characteristic (ROC) curves.2 = 0.88, P<0.01). Bland–Altman plot indicated a moderate agreement of cylinder values between the two methods. Based on the criteria specified by the AAPOS 2013 guidelines, the sensitivity and specificity (in respective order) for detecting hyperopia were 98.31% and 97.14%; for detecting myopia were 78.50% and 88.64%; for detecting astigmatism were 90.91% and 80.37%; for detecting anisometropia were 93.10% and 85.25%; and for detection of strabismus was 77.55% and 88.18%.The mean refractive errors measured with the Spot were: spherical equivalent (SE) = 0.70 ± 1.99 D, J0 = 0.87 ± 1.01 D, J45 = 0.09 ± 0.60 D. The mean results from retinoscopy were: SE = 1.19 ± 2.22 D, J0 = 0.77 ± 1.00 D, J45 = -0.02 ± 0.45 D. There was a strong linear agreement between results obtained from those two methods (RThe refractive values measured from Spot photoscreener showed a moderate agreement with the results from cycloplegic retinoscopy refraction, however there was an overall myopic shift of -0.49D. The performance in detecting individual amblyopia risk factors was satisfactory, but could be further improved by optimizing criteria based on ROC curves. Amblyopia is the most common cause of preventable vision impairment in children with a prevalence of 1.6% to 3.6% in industrialized nations. The risInstrument-based screening is a quick process that needs little cooperation of children and has been regarded as the preferred option for vision screening especially for developmentally delayed and preverbal children , 9. SpotRecently, there have been some reports of the sensitivity and specificity of the Spot for screening amblyopia risk factors–12. AlthThe ethics Board of Tianjin Medical University Eye Hospital approved the study and parental consent was obtained prior to the start of the study. All questions and concerns were addressed before the consent forms were signed. The conduct of the study followed the tenets of the Declaration of Helsinki. Considering the low prevalence of optical deprivation such as congenital cataract or ptosis, those diseases were excluded in our study. Children attending the eye hospital either for screening or for a check-up within the age group of 4 to 7 years were recruited in this study.All patients were examined in the following order: (1) complete ophthalmologic examination; (2) photoscreening with Spot; (3) cycloplegia; (4) retinoscopy. In the photoscreening procedure, the Spot was performed at a distance of one meter from the child. The Spot measurement range is +/- 7.50 D. If the refraction was out of range, >7.50 or <-7.50 would be displayed on the touch screen. The tesSE = S + C / 2; J0 = (−C / 2)*cos(2 * ∂); J45 = (−C / 2)*sin(2 * ∂). Anisometropia was calculated as the interocular difference in SE.Refractive errors  were measured five times by retinoscopy in each eye, and mean vector value was calculated as final result. Spherical equivalent (SE) and vector presentation of astigmatism J0 and J45 were calculated according to the following formulas: Amblyopia risk factors were based on the AAPOS 2013 guidelines for ages over 48 months: hyperopia >3.5 D in any meridian, myopia >-1.5 D in any meridian, astigmatism >1.5 D in any meridian; anisometropia >1.5D, manifest strabismus in primary position >8PD [Descriptive statistics included measurements of means, standard deviations and frequencies. Since Kolmogorov-Smirnov test indicated that data were not normally distributed, Wilcoxon signed-rank test was applied to test if the difference between the results obtained from Spot photoscreener and retinoscopy was significant. Linear, quadratic, cubic models were constructed to assess the correlation between the results obtained from those two methods. Bland-Altman plots were used to assess the agreement between Spot and retinoscopy. Receiver Operating Characteristic (ROC) curve was employed to select the best cutoff points related to appropriate sensitivity and specificity of the Spot to detect amblyopia risk factors. All statistical analyses were performed using SPSS statistical package 19 . Statistical significance was defined as p<0.05.A total of 168 children were screened. Measurement could not be done in 13 (8.4%) children. Among those 13 children, five would not cooperate due to fear, three had high hyperopia accompanied with esotropia, two had congenital ptosis, two had congenital nystagmus, and one had congenital cataract. Measurement was successfully obtained from155 children (310 eyes), with age ranging from 4–7 years (means 5.74 ± 1.20 years). Seventy-one (45.8%) were girls and 84 (54.2%) were boys. Twenty-six children (16.8%) had amblyopia as defined by guidelines of PPP [The mean refractive errors measured with Spot photoscreener and cycloplegic retinoscopy are summarized in The mean difference of refractive errors between Spot photoscreener and cycloplegic retinoscopy are showed in SEspot = −0.30 + 0.84 × SEcr, R2 = 0.88, P<0.01, black line 2 = 0.80 for both quadratic and cubic fitting . Quadratic and cubic fitting did not improve R2 much (R2 = 0.64 for quadratic and cubic fitting). For J45, the correlation between retinoscopy and Spot was further reduced (R2 = 0.24 for linear fitting R2 = 0.64 for both quadratic and cubic fitting). This may be due to the fact that most subjects had low astigmatism.For J0, the linear correlation between retinoscopy and Spot was not as strong , and a sensitivity of 85% and a specificity of 88% after applying the updated referral criteria (v1.1.51). The updA photoscreener is mainly used for the detection of amblyopia risk factors. In our study, Spot had a sensitivity of 94.79% and specificity of 85% for the detection of amblyopia risk factors. Armitage studied the performance of Plusoptix S12 in detecting amblyopia risk factors. The sensitivity and specificity was 91% and 78% respectively . Matta eOnly manifest strabismus was considered in this study since AAPOS 2013 guidelines does not include intermittent exotropia [The refractive values measured from Spot photoscreener showed a moderate agreement of the result from cycloplegic retinoscopy. The performance of Spot in detecting individual amblyopia risk factors was satisfactory, although could be further improved by optimizing criteria based on ROC curves. Those finding suggested that Spot could be a very useful tool for large-scale population screening in Chinese population.


HIV testing and retention in care treatment are key strategies towards an AIDS free generation. Immediate treament of HIV patients with the lowest CD4 T cell counts is critical given their high rates of pre-antiretroviral therapy mortality. We evaluated the impact of adding an additional nurse-counsellor on HIV outcomes among patients enrolled in care in 7 urban public clinics in Kampala, Uganda.One additional research nurse per clinic was specifically tasked with identifying and tracking HIV-infected persons with CD4<100 cells/μL who were lost, and expediting ART initiation among patients enrolled after July 2012. Data were also retrospectively collected on all patients with CD4<100 cells/μL that registered at these clinics in the latter six months of 2011. We compared time from CD4 blood draw to ART initiation, frequency of CD4 testing and 6 month retention-in-care by time period. Analyses of categorical and continuous variables were conducted using Χ2 and Mann-Whitney tests.A total of 258 patients in the 2011 cohort and 593 in the 2012 cohort completed 6 months from clinic registration. Median age of patients in both cohorts was 32 years and 55% were female. Median CD4 cells/μL  count in the 2011 cohort was 34  and 43  in 2012 (p < 0.002). Median days from CD4 blood draw to ART initiation reduced from 42  in the 2011 to 33  in 2012, p < 0.001. Six-month retention in care was 62.0% (160/258) in 2011 cohort compared to 75.9% (450/593) in 2012 (p < 0.001). Among the patients retained in care, 24.4% (39/160) received a CD4 count test at 6 months versus 53.3% (240/450) in the 2012 cohort.The addition of one nurse per clinic to identify and follow severely immune-compromised new clinic patients with CD4<100 led to improved patient care and better outcomes. Funder: The study is an Implementation Science project funded by CDC.


Cryptosporidium commonly infects cattle throughout the world and Iran. The present study was undertaken to determine the abundance and associated risk factors of Cryptosporidium infection in cattle herds of northwestern Iran. A total number of 246 fecal samples from 138 (56.1%) diarrheic (D) and 108 (43.9%) non-diarrheic (ND) cattle were randomly collected and examined by fecal smears stained with Ziehl-Neelsen. For molecular specification, DNA was extracted from collected Cryptosporidium oocysts and a fragment of 1325 bp in size from 18S rRNA gene was amplified. The overall prevalence of Cryptosporidium infection was 22.3% (55/246). The prevalence of Cryptosporidium infection in examined calves less than 6 month-old was significantly higher than adult cattle. C. parvum and C. andersoni were identified in 20.3% (50/246) and 2.03% (5/246) of examined cattle, respectively. The highest prevalence of C. parvum infection was found in D calves < 6 month-old , while C. andersoni was only detected in ND cattle . There was significant difference in the prevalence between male than female cattle. There was no significant difference between prevalence and seasons of investigation. It was concluded that C. parvum was the prevalent species in younger animals compared to older ones as a potentially zoonotic agent in the region.The protozoan intestinal parasite  Cryptosporidium an obligate intracellular protozoan parasite is a frequent cause of intestinal, gastric or respiratory cryptosporidiosis in a wide range of animals and humans hosts worldwide.1 Some of the zoonotic Cryptosporidium species usually causes self-limiting diarrhea in humans and animals. Cryptosporidiosis was reported for the first in 1971,2 as well as from Iranian cattle in 1984,3 and increasingly in a range of hosts.1,4-7Cryptosporidium species. Currently, 20 different species of Cryptosporidium has been reported which C. parvum, C. bovis, C. ryanae, Cryptosporidium deer-like genotype, and C. andersoni are considered as cattle adapted.8 Of those, the intestinal specie C. parvum has zoonotic potential and is a frequent cause of human cryptosporidiosis.9,10 In terms of economic losses, C. parvum is considered as the most important species among cryptosporidial agents.11Cryptosporidium andersoni as an abomasal parasite has been associated with reduced milk yield in dairy cattle and decreased weight gain in post weaned calves.12Over the past two decades, cattle have been identified as a common reservoir host for et al., a high diversity of Cryptosporidium genus based on several molecular markers, the 18S rRNA gene, has been shown by multilocus DNA analysis.10 In Iran, molecular detection of Cryptosporidium in humans has been undertaken by several researchers.11,13,14 While, to date, the molecular study for confirming cattle Cryptosporidium infection has not been investigated in this part of Iran. Additionally, the nationwide epidemiological survey is essential for the exact knowledge of infection status of C. parvum and C. andersoni in the country. Therefore, it is important to determine bovine Cryptosporidium infection and major risk factors in order to screen C. parvum and C. andersoni harboring in cattle herds of northwestern Iran.According to Xiao Study area. The study area  is located in northwest of Iran with two rainy seasons, the first from March to May and the second in October-November. The study was carried out in the mountainous, mountainside and plain areas of Urmia suburb covering 355 villages that fall within a radius of 20 to 125 km of the city center , a total number of 101 cattle and 145 calves from 16 herds (375 cattle) were randomly selected from cattle herds in Urmia suburban of WAP. The herds examined were raised following traditional husbandry practices, with animals being mainly cross-breeds and indigenous crossbred. The major risk factors for Cryptosporidium infection were host, Cryptosporidium species, and environmental factors (16 The consistency (Fc) of fecal specimens (D or ND) were recorded. The sample size for determining prevalence was estimated based on the formula  presented by Thrusfield.16 factors . The catSample processing and examination. In each farm and herd, an amount of 25 g fresh fecal samples was collected directly from the rectum of each individual cattle and or calves and fecal smears were prepared. The Cryptosporidium oocysts were initially screened using the modified Ziehl-Neelsen staining method.18 The parasite species was identified by morphologic and morphometeric criteria which measured at 1000× magnification. Morphologically, C. parvum (5.0 × 4.5 µm) oocysts were discriminated from C. andersoni oocysts (7.6 × 5.6 µm).19Molecular procedures. Since, the modified Ziehl-Neelsen staining is a non-specific staining procedure the PCR procedure was performed to specify genus Cryptosporidium. For this purpose, oocysts were purified from fecal specimens of infected cattle using sucrose gradients as described by Arrowood and Sterling 20 and subjected to molecular analysis. To rupture Cryptosporidium oocysts, 10 times freeze-thaw cycles were performed using liquid nitrogen.21 Genomic DNA was extracted by modified phenol-chloroform method using cetyltrimethylammonium bromide (CTAB) at 60 ˚C for 1 hr.22Cryptosporidium was amplified using two primers (Cryptosense: 5'- TTCTAGAGCTAATACATGCG-3' and Crypto-antisense: 5'- CCCTAATCCTTCGAAACAGGA -3').23 PCR reaction was carried out in a 25 µL reaction mixture containing 3 µL of genomic DNA (diluted 1:30), 0.5 µL of Taq DNA polymerase , 4 µL of 1.25 mM dNTPs , 1 µL of 50 mM MgCl2, 2.5 µL of 10X PCR reaction buffer, 1 µL of each primer (25 µM). The samples were subjected to an initial denaturation step at 94 ˚C for 5 min, followed by 35 cycles of 45 sec at 94 ˚C, 45 sec at 55 ˚C, and 90 sec at 72 ˚C, and a final extension step at 72 ˚C for 7 min. The PCR product was analyzed by electrophoresis on 1.5% (w/v) agarose gel and visualized by staining with 1% ethidium bromide.A fragment of 1325 bp of the 18S rRNA gene of Statistical analysis. Statistical evaluation was undertaken to compare obtained data with confidence interval of 95% using non-parametric Fisher’s exact test . Probability values of p < 0.05 were regarded statistically significant.Cryptosporidium oocysts were nearly spherical in shape and contained four sporozoites. Based on the size, C. andersoni oocysts were morphologically distinguishable from C. parvum oocysts. The average diameter for C. parvum oocysts ranged from 4.5 to 5.0 µm and shape index (SI) as 1.1 ± 0.2, whereas larger C. andersoni oocysts ranged from 6.5 to 7.9 µm in size with SI as 1.3 ± 0.4. The detected C. parvum and C. andersoni infection in D or ND cattle and or calves of different age groups have been shown in Cryptosporidium infection was 22.3% (55/246) which confirmed by PCR . The prevalence of Cryptosporidium infection was also significantly higher in 13.4% (33/246) D than 8.9% (22/246) ND cattle (p = 0.025). Among the samples that were positive for Cryptosporidium species, 29 out of 246 (11.7%) were from male and 26 out of 246 (10.5%) were from female cattle (p = 0.026). The highest prevalence of C. parvum infection was found in D calves , while C. andersoni was only detected in ND cattle  examined in which grazed in plain areas of the region (p = 0.0001). Cryptosporidium parvum were detected in all examined herds while C. andersoni only detected in three herds (18.8%). Mixed infection with both Cryptosporidium species was also found in 2.4% (6/246) of infected cattle. There was no significant difference between the prevalence and seasons of investigation (p > 0.05).The prevalence of d by PCR . Out of ectively . The pre24,25 it was revealed that cattle in the region harbored at least two Cryptosporidium species. The small oocysts (mean size: 4.3 ± 0.2 µm) were identified as C. parvum (20.3%) and the large ones (average size: 6.8 ± 0.3 µm) were as C. andersoni (2.0%). Cryptosporidium parvum has been reported to be prevalent in neonates’ worldwide14,26 and was not found in older cattle in any examined herds of the region. Therefore, the higher infection rate of C. parvum in current study compared to that of C. andersoni appears to reflect the dominance of C. parvum. Cryptosporidium andersoni has been reported for the first time in Iran by Sohrabi Haghdust.3 Thus, this was the first report of C.andersoni occurrence in cattle of northwestern Iran. In this work, no C. andersoni oocysts were detected in cattle < 1 years old, supporting other reports that chronic C. andersoni infection usually occurs in adult cattle with no clinical symptoms.14,21,27 The prevalence of the abomasal species C.andersoni was reported to be high in adult cattle while it is less pathogenic.26-29Based on morphological characterization described by other researchers,Cryptosporidium distribution pattern and prevalence have been reported in many countries throughout the world25,30 and Iran.31,32 The results of the present work revealed that the estimated prevalence was similar to those reported in the previous researches.14,33 Reported Cryptosporidium infection prevalence by other researchers varied from 22.0 to 59.0% worldwide24 and 3.8 to 42.8% in Iran.7,14,31,32 Seasonal changes in prevalence of Cryptosporidium infection were observed in spring and summer in the region. However, there was no significant association. In India, the highest prevalence of Cryptosporidium infection in cattle was reported in rainy season followed by summer and winter (p < 0.01).34 These trends may reflect direct zoonotic contact and indirect effects of rainfall, farming events such as calving, and environmental pollution with farm waste.2C. parvum was decreased with increasing age. The age related distribution of C. parvum infection in this age group was similar to that previously reported in cattle of other parts of Iran.14,32Cryptosporidium parvum has been also reported to primarily infect D young calves and shed the specie.26,30 It seems that ND older cattle with low prevalence and without clinical symptoms of cryptosporidiosis may serve as carriers for young calves with an immature immune system in the region. Cryptosporidium infection in this study was considered to be a probable cause of diarrhea in neonates as significant association was found in previous studies.30,35,36 Fotouhi Ardekani et al. found significant difference between D (31.8%) and ND (17.4%) conditions.14 Also, Brook et al. noted that age was correlated with consistency of the feces 30 so that in younger animals, feces are tending to be looser due to the liquid nature of the milk diet. Sex of examined cattle in the present study had also significant association with the prevalence. This finding was in concordance with previous research by Radfar et al.32In the present study, the age of examined cattle had significant effect on the prevalence. In addition, the prevalence of C. parvum is the most common species in cattle and farms should be also considered as a potential source of surface water contamination. Thus, further investigations may reveal more information about economic effects of this parasite and public health concern in the region. Furthermore the source of infection should be investigated and control measures should be established in the future. The findings described in this investigation suggested that


Objective. Aim of this audit was to analyze indications, complications, and correlation of preoperative diagnosis with final histopathology report of all hysterectomies, performed in a premier teaching hospital. Methods. Present study involved all patients who underwent hysterectomy at a premier university hospital in Southern India, in one year . Results. Most common surgical approach was abdominal (74.7%), followed by vaginal (17.8%), and laparoscopic (6.6%) hysterectomy. Most common indication for hysterectomy was symptomatic fibroid uterus (39.9%), followed by uterovaginal prolapse (16.3%). Overall complication rate was 8.5%. Around 84% had the same pathology as suspected preoperatively. Only 6  had no significant pathology in their hysterectomy specimen. Conclusion. Hysterectomy is used commonly to improve the quality of life; however at times it is a lifesaving procedure. As any surgical procedure is associated with a risk of complications, the indication should be carefully evaluated. With the emergence of many conservative approaches to deal with benign gynecological conditions, it is prudent to discuss available options with the patient before taking a direct decision of surgically removing her uterus. Hysterectomy is the second most frequently performed major surgical procedures on women all over the world, next only to cesarean. In US, approximately 600,000 hysterectomies are performed each year . In IndiIndications of hysterectomy vary from benign condition to malignancies of genital tract. Term “hysterectomy” though means removal of uterus, in practice it has a much wider classification depending upon the indication. At times it is done without removal of the cervix  or with removal of adnexa . It can also be a part of staging laparotomy or radical hysterectomy. Hysterectomy can be performed abdominally, vaginally or through abdominal ports with help of a laparoscope. Approach depends on surgeon's preference, indication for surgery, nature of disease, and patient characteristics.As any other surgery, hysterectomy is also associated with intraoperative and postoperative complications. Rates of various complications with hysterectomy have been reported in the range from 0.5% to 43% ), followed by vaginal (n = 94 [17.8%]), and laparoscopic (n = 35 [6.6%])  . Most of [6.6%]) . Mean ag [6.6%]) . Four of [6.6%]) , all of n = 210 [39.9%]), followed by utero-vaginal prolapse (n = 86 [16.3%]). Other indications being dysfunctional uterine bleeding (DUB) (n = 43 [8.1%]), adenomyosis (n = 21 [3.9%]), endometriosis (n = 7 [1.3%]), benign (n = 42 [7.9%]) and malignant (n = 47 [8.9%]) ovarian tumors, endometrial hyperplasia (n = 25 [4.7%]) and endometrial cancer (n = 20 [3.7%]), premalignant disease of cervix (n = 17 [3.2%]), and early stage cervical cancer (n = 4 [0.7%]). Less common indications were recurrent postmenopausal bleeding of undetermined cause (n = 16 [2.8%]) and chronic pelvic inflammatory disease (PID) (n = 8 [1.5%]). Obstetric hysterectomy was performed in 8 (1.5%) cases (Tables Most common indication for hysterectomy was symptomatic fibroid uterus (n = 210 9.9%), foTwo women undergoing TAH with BSO sustained bowel injury, one in a case of tubo-ovarian mass and other in a malignant ovarian tumor. Bladder was injured accidentally in four cases of abdominal hysterectomies (1.01%) and in one VH with PFR (1.06%). One patient during abdominal hysterectomy had ureteric injury which required Boari's flap. Postoperatively ten  patients had wound infection or gaping. Two (0.5%) had burst abdomen. Two patients  had pelvic abscess which were managed conservatively. Two women had postoperative intestinal obstruction. One was managed conservatively. Other underwent exploratory laparotomy, adhesiolysis with resection anastomosis on the twelfth day following hysterectomy. On the sixth postoperative day following laparotomy she succumbed due to respiratory distress syndrome .Twenty-one women (3.9%) had blood loss of more than 1000 mL during surgery and required multiple transfusions. Among these twenty had undergone abdominal hysterectomy  and one underwent NDVH for DUB.One VH had to be converted to laparotomy due to adhesions. For one VH minilaparotomy was done to achieve complete hemostasis. One staging laparotomy for malignant ovarian tumor was abandoned because of frozen pelvis, and only biopsies were taken in order to start neoadjuvant chemotherapy.Five women required intensive care admission after surgery. One lady died after two days following peripartum hysterectomy. One lady developed multiple organ dysfunction syndrome (MODS) and was discharged at request in a moribund condition. Mean duration of hospital stay in abdominal, vaginal, and laparoscopic approach was, respectively, 8.7 ± 2.8, 6.8 ± 1.6, and 6.1 ± 2.6 days.In a total of 47 [8.9%] cases intraoperative consultation was sought by either an oncosurgeon, urosurgeon, or a general surgeon. Most of these cases were abdominal hysterectomies, where in 15 cases of malignant disease an oncosurgeon was part of the team. In 26 cases assistance from general surgeons was sought for release of dense bowel adhesions. Assistance from urosurgeons was sought in six cases.For correlation of final histopathology with preoperative diagnosis, 11 emergency hysterectomies done to save life were excluded. Among the rest 516 hysterectomies 434 (84.1%) had the same pathology as it was suspected preoperatively. Around a fifth  was found to have an extra pathology that might have required surgical treatment. 85 (16.4%) were found to have a pathology which was different from the preoperative diagnosis. Among these were six patients with a preoperative diagnosis of malignant ovarian tumor, out of which three came out to be benign, one was Krukenberg's tumor, one was GIST, and one turned out to be fallopian tube carcinoma. One case preoperatively diagnosed as hydrosalpinx also turned out to be fallopian tube carcinoma. Three patients with preoperative normal Pap smears had cervical intraepithelial neoplasia: high grade (CIN II/III) in the hysterectomy specimen. Two cases of prolapse had incidental finding of squamous cell carcinoma in histopathology. Two cases operated for endometrial hyperplasia had foci of carcinoma in our series. Only six (five with preoperative diagnosis of AUB and one with CIN II) had no significant pathology in their hysterectomy specimen.In our institution in a span of one year we performed 527 hysterectomies. Most of these were abdominal (75.5%) followed by vaginal 17.8%) and laparoscopic (6.6%). Almost the same observations come from Canada  [% and lapMost common indication in abdominal approach was fibroid uterus , while in vaginal it was uterovaginal prolapse . A study evaluating the appropriateness of recommendation for hysterectomy in USA also found fibroid (60%) to be the most common indication followed by prolapse 11%) . In the % . In thP < 0.05). In Hong Kong the incidence of complications for vaginal hysterectomy (17.0%) was lower than that for both abdominal (26.4%) (P < 0.001) and laparoscopic hysterectomy (23.9%) (P < 0.05) [P < 0.05).Overall complication rate was 8.5%. Abdominal approach had a complication rate of 10.9%, as compared to 2.1% in vaginal approach ( < 0.05) . HoweverMean duration of stay in our hospital following hysterectomy by any route was more than other studies. In abdominal, vaginal and laparoscopic approach was, respectively, 8.7 ± 2.8, 6.8 ± 1.6, and 6.1 ± 2.6 days, as compared to study from Hong Kong where it was found to be 6.7 ± 2.5, 4.9 ± 2.4, and 4.2 ± 3.4 days [Hysterectomy remains a matter of diverse debate owing to its physical, emotional, economic, sexual, and medical significance to women . In a stThere is a concern among the medical and health policy community that hysterectomy is used too frequently as a first line treatment. It is a well-known fact that in order to achieve the most favorable outcome, appropriateness of surgery must be carefully evaluated along with all available options in context of the disease process like medical management, endometrial ablation, UAE, and levonorgestrol intrauterine system (LNG-IUS). Oral medication suits a minority of women long term . EndometAccording to Magon et al. hysterectomy is a surgery which has been used and misused, underused, and abused at different times in gynecology . Hystere


HIV prevalence among pregnant women ages 15–49 declined from 7.1% to 2.0% in urban areas between 1998 and 2014, and from 2.0% to 0.5% in rural areas between 2003 and 2014; similar declines were reported in the Demographic and Health Surveys. During the same time period, individuals reported safer sex behaviors, including delayed sexual debut and reduced number of sex partners among youth, as well as increased condom use at last sex with nonmarital partners among men and women ages 15–49. HIV prevalence among pregnant women ages 15–49 declined from 7.1% to 2.0% in urban areas between 1998 and 2014, and from 2.0% to 0.5% in rural areas between 2003 and 2014; similar declines were reported in the Demographic and Health Surveys. During the same time period, individuals reported safer sex behaviors, including delayed sexual debut and reduced number of sex partners among youth, as well as increased condom use at last sex with nonmarital partners among men and women ages 15–49. To investigate trends in HIV prevalence and changes in reported sexual behaviors between 1998 and 2014 in Burkina Faso.We obtained data on HIV prevalence from antenatal care (ANC) surveillance sites (N = 9) that were consistently included in surveillance between 1998 and 2014. We also analyzed data on HIV prevalence and reported sex behaviors from 3 population-based surveys from the Demographic and Health Surveys (DHS), conducted in 1998–99, 2003, and 2010. Sex behavior indicators comprised never-married youth who have never had sex; sex with more than 1 partner; sex with a nonmarital, non-cohabiting partner; condom use at last sex with a nonmarital, non-cohabiting partner; and sex before age 15. We calculated survey-specific HIV prevalence with 95% confidence intervals (CIs) and used the chi-square test or chi-square test for trend to compare HIV prevalence across survey years and to analyze trends in reported sex behaviors.HIV prevalence among pregnant women ages 15–49 decreased by 72% in urban areas, from 7.1% in 1998 to 2.0% in 2014, and by 75% in rural areas, from 2.0% in 2003 to 0.5% in 2014. HIV declined most in younger age groups, which is a good reflection of recent incidence, with declines of 55% among 15–19-year-olds, 72% among 20–24-year-olds, 40% among 25–29-year-olds, and 7% among those ≥30 years old . Data reported in the DHS corroborated these declines in HIV prevalence: between 2003 and 2010, HIV prevalence dropped significantly—by 89% among girls ages 15–19, from 0.9%  to 0.1% , and by 78% among young women ages 20–24, from 1.8%  to 0.4% . During the same time period, people reported safer sex behaviors. For example, significantly higher percentages of never-married youth reported they had never had sex, lower percentages of sexually active youth reported multiple sex partners, and lower percentages of youth reported having sex before age 15. In addition, the percentage of men ages 20–49 reporting sex with a nonmarital, non-cohabiting partner declined significantly, while condom use at last sex with such a partner increased significantly among both men and women ages 15–49.Both ANC surveillance and population-based surveys report sharp declines in HIV prevalence in Burkina Faso between 1998 and 2014, accompanied by improvements in reported risky sex behaviors. HIV prevalence in Burkina Faso declined substantially over the past 10 to 15 years, from 2.2% in 2001 to 1.0% in 2012, according to a recent report from the Joint United Nations Programme on HIV/AIDS (UNAIDS).Improvements in risky sex behaviors can reduce HIV incidence.-There is considerable discussion in the literature about the declining trend in HIV prevalence among young pregnant women in sub-Saharan Africa in relation to sexual behaviors.In this article, we analyze the possible factors behind the considerable HIV decline in Burkina Faso with a focus on changes in sexual behavior.We analyzed trends in HIV prevalence in Burkina Faso over a 16-year period. Data came from national ANC surveillance surveys conducted between 1998 and 2014 as well as from national surveys conducted by the Demographic and Health Surveys (DHS) program in 1998–99, 2003, and 2010. We also analyzed trends in reported sex behaviors from the DHS.We analyzed trends in HIV prevalence in Burkina Faso from ANC surveillance and DHS surveys, along with trends in reported sex behaviors.The HIV serosurveillance system of pregnant women was established in Burkina Faso in 1997, initially with 3 urban sites. The system evolved over time, covering 5 urban sites in 1998 and 10 urban and rural sites in 2003 . Since 2004, 13 sites have been included in the surveillance system . The progressive increase in sentinel sites was meant to provide a roughly representative picture of levels and trends in HIV prevalence throughout the country. To avoid potential bias as a result of expanding ANC surveillance over time, only data from those urban sites that were consistently included in surveillance between 1998 and 2014  and the rural sites included between 2003 and 2014  were included in the analysis. Pregnant women presenting for the first time for their current pregnancy at the participating ANC sites during the survey period were enrolled in an anonymous unlinked HIV serosurvey.We also obtained data from the DHS on HIV prevalence and reported sexual behavior. As reported elsewhere, the DHS was designed to obtain national and regional estimates of HIV prevalence and associated sociodemographic and behavioral indicators among women and men.We assessed trends in 5 key indicators related to sexual behaviors, in addition to the percentage of young people ages 15–24 years who reported having ever tested for HIV and the percentage of young people who reported knowing a formal source of condoms. The behavioral indicators were:never had sexThe percentage of never-married young women and men ages 15–24 who have sex with more than 1 partner in the last 12 months among all young people who have been sexually active in the last 12 monthsThe percentage of young people (ages 15–24) who have had sex with a nonmarital, non-cohabiting partner in the last 12 months among all respondents reporting sexual activity in the last 12 monthsThe percentage of respondents who have had using a condom the last time they had sex with a nonmarital, non-cohabiting partner among those who have had sex with such a partner in the last 12 monthsThe percentage of respondents who reported sex before age 15The percentage of young women and men ages 15–24 who have had To describe HIV prevalence trends by data source, we calculated survey-specific HIV prevalence with 95% binomial confidence intervals (CIs). To determine the relative proportional change in prevalence across survey year, the difference between estimates from the earlier and later rounds was divided by the earlier estimate. When comparing HIV prevalence across survey years, we used the chi-square test or the chi-square test for trend. Trends in reported sexual risk behavior were analyzed using the same tests.The number of pregnant women ages 15–49 years included in the ANC surveillance surveys varied from 2,010 in 1998 (from urban areas only) to 3,129 in 2014 , with a maximum of 3,276 in 2008 . Between 1998 and 2003, HIV prevalence declined among 15–49-year-old pregnant women in urban areas  from 7.1% to 3.5%, a decline of 51% . While pBetween 1998 and 2014, HIV prevalence declined among pregnant women ages 15–49 in both urban and rural areas.Age-specific data were available between 2007 and 2014. These data  indicate HIV prevalence declined most in younger age groups with declines of 55% among 15–19-year-olds, 72% among 20–24-year-olds, 40% among 25–29-year-olds, and 7% among those ≥30 years old .HIV prevalence declined most in younger age groups.P = .04), from 0.9%  to 0.1%  (P = .001) over the same time period, from 1.8%  to 0.4% , and among women ages 25–29, it dropped by 52%, from 2.5%  to 1.2% .The decline in HIV prevalence among pregnant women in the ANC surveillance surveys was consistent with HIV prevalence data collected by the DHS. Between the 2003 and 2010 DHS, HIV prevalence among girls ages 15–19 dropped by 89% ( to 0.4) . Among yP = .001), from 2.8%  to 0.5%   to 0.4%  , whereas for men ages 25–29 HIV prevalence declined significantly by 82% ( to 1.2) .never had sex increased significantly between 2003 and 2010 among both girls and boys: for girls, from 76.1% to 82.4% (P<.001); for boys, from 74.4% to 82.1% (P<.001) (P<.001). Among never-married young men ages 20–24, the increase was smaller and not statistically significant: 32.8% in 2003 to 33.8% in 2010 (P = .68).The percentage of never-married adolescents ages 15–19 who reported they had (P<.001) . The perThe percentage of never-married adolescents who reported they had never had sex increased significantly between 2003 and 2010.multiple partners in the last year fell from 7.9% to 2.4% (P<.001) between 1998–99 and 2010, whereas a smaller decline was observed among sexually active young women ages 20–24  (P<.001) and from 36.4% to 17.4% (P<.001), respectively.The percentage of sexually active girls ages 15–19 who reported having P = .04) . SubstanThe percentage of youth reporting multiple sex partners declined significantly between 1998 and 2010.sex with a nonmarital, non-cohabiting partner in the last year has always been quite low and has remained stable during the study period (8.3% in 1998–99 to 7.9% in 2010). The percentage of sexually active boys ages 15–19 who reported engaging in sex with a nonmarital, non-cohabiting partner in the last 12 months also remained unchanged (94.1% in 1998–99 to 94.2% in 2010), whereas the percentages declined significantly from 73.8% to 65.8% (P = .009) among young men ages 20–24 and from 20.0% to 17.1% (P<.001) among older men ages 25–49  among women and from 57.4% to 73.9% among men (P<.001). This percentage increased significantly among girls ages 15–19, from 38.6% in 1998–99 to 52.6% in 2010 (P<.001), as well as among boys ages 15–19, from 45.3% to 67.7% (P<.001). Similar trends were also evident among men and women in older age groups  among young women and from 7.6% to 1.9% (P<.001) among young men.Among both young women and men ages 15–24, the percentage having The percentage of youth who reported having sex before age 15 declined significantly between 1998 and 2010.HIV testing rates among men increased significantly between 2003 and 2010, increasing most in younger age groups—by 67.4% among 15–19-year-olds (P<.001) and 66.0% among 20–24-year-olds (P<.001), compared with 63.5% among 25–49-year-olds (P<.001) ((P<.001) . Overallknowing a formal source of condoms increased from 44.3% to 73.1% (P<.001) and from 63.1% to 85.0% (P<.001), respectively, between 2003 and 2010. The percentage among young women and men ages 20–24 increased from 49.6% to 79.6% (P<.001) and from 83.3% to 96.9% (P<.001), respectively, between 2003 and 2010.The percentage of adolescent girls and boys ages 15–19 who reported -,,We analyzed and assessed, for the first time, all data available on trends in HIV prevalence in Burkina Faso from the onset of the epidemic. These data provide a consistent picture of a decline in HIV prevalence among pregnant women ages 15–49 starting in 1998 and continuing up to 2003, from 7.1% to 3.5%, followed by further decline after 2007 to 2.0% in 2014. National DHS data also indicate a reduction of HIV prevalence in the country. The declining trend in HIV prevalence among pregnant women, particularly those ages 15–19 described here, is consistent with data from several other sub-Saharan African countries during a similar time period.,,,We also presented the first comparisons of data on trends in sexual behavior of comparable populations over time since the onset of the HIV epidemic. The percentage of never-married young women and men ages 15–24 who have never had sex increased substantially during precisely the same time period as when HIV prevalence dropped. Furthermore, the percentage of young individuals reporting having multiple partners decreased, particularly among males, while reported condom use at last sex with non-regular partners increased. Taken together, these trends suggest that the reduction in HIV prevalence was, at least in part, due to a reduction in HIV incidence but also to a strong decline in HIV prevalence among older men . Indeed, HIV prevalence among young people ages 15–24 can provide useful indications of trends in HIV incidence, and behavior change among older people, particularly men, could cause reductions in prevalence among young people. The results of these nationwide surveys are consistent with cross-sectional surveys of HIV prevalence and risky behaviors in other countries, all of which demonstrate that the most common behavioral changes involved delays in sexual initiation,The temporal order of these changes in behavior and declines in HIV prevalence after 2007 is supported by programmatic efforts occurring during that time. From 2006 to 2010, Burkina Faso established an HIV strategic framework with central coordination. The number of sites for the prevention of mother-to-child transmission of HIV (PMTCT) rose to 780 in 2007, 3 times higher than in 2006, and climbed to 1,226 in 2010. From 2007 onwards, awareness campaigns on female and male condom use were active in all sectors . Moreover, the number of health facilities with a counseling center and a voluntary testing center tripled between 2006 and 2007, from 284 to 837, continuing to increase to 1,305 in 2010.-The decline in HIV prevalence in the Burkina Faso DHS was much higher among young women than young men. In 2010, HIV prevalence among young men was as high, or higher, than among women, which is very unusual. In Africa as a whole, women ages 15–24 are infected with HIV at rates 2.5 times that of young men.Although HIV decline in Burkina Faso was paralleled with safer sexual behaviors, these findings have limitations. Data collected on sexual behaviors over time may be subject to social desirability bias, as prevention programs can change the social norms regarding sexual behavior.Findings from the current study are consistent with previous work indicating that observed declines in HIV prevalence or incidence were coincident with reductions in sexual risk behavior in countries with generalized HIV epidemics.Declines in HIV prevalence were coincident with reductions in sexual risk behavior in Burkina Faso.


The Hepatitis C Virus (HCV) is considered essentially hepatotropic, yet the virus compartments have also been found in important extra hepatic sites. Detection of HCV RNA in extra hepatic reservoirs such as peripheral blood mononuclear cells (PBMCs) is important for determining disease progression and treatment effectiveness.The present study aimed to determine different HCV genotypes in patients' plasma and PBMC specimens, in Jahrom city of Iran.6 PBMCs, Real-time PCR was performed, using specific-genotype primers. Finally, data analysis was done by the Statistical Package for Social Sciences (SPSS) software.Blood samples of 137 patients with established HCV were collected at the Honari clinic. These patients were anti-HCV and plasma HCV RNA positive. After plasma RNA extraction and obtaining a pellet of approximately 3-5 × 10Subtype 3 was the most common genotype in plasma (57.7%) and PBMCs (51.1%). Subtype 1a was detected in 36.5% and 30.7% of plasma samples and PBMCs, respectively whereas subtype 4 was not detected in any of the cases. There was a genotype difference between plasma and PBMCs of 12.4% of patients. In four patients no genotype was detected in their plasma but genotype 3 was detected in the PBMCs.It is suggested that determination of the target genotype by plasma subtyping for choosing the proper antiviral therapy is essential but may result in therapy failure. HCV genotyping in PBMC samples, along with plasma specimens, might be more beneficial. Therefore determining the HCV genotype in PBMCs, before beginning the therapy is useful due to the possibility of occult infection detection. Hepatitis C virus (HCV) belongs to genus Hepacivirus and the Flaviviridae family, and was first isolated in 1989 . HCV genThe present study aimed to distinguish different hepatitis C genotypes in plasma and PBMCs, of patients from Jahrom city, Iran.In this cross-sectional study, 137 established anti-HCV positive individuals, referred to the Honari clinic  from November 2012 to March 2013 were enrolled. Written consent forms, compiled by the Ethics Committee of Jahrom University of Medical Sciences were signed by the patients. Inclusion criteria were positive anti-HCV accompanied by the presence of plasma HCV RNA. Patients who were positive for anti-HCV antibodies but negative for HCV RNA were excluded from the study. Anti-HCV detection was performed by a third generation enzyme immunoassay, based on the manufacturers’ guidance . Hepatitis C plasma RNA was detectedby thereal-time PCR method. Plasma samples were kept frozen and stored at -70°C until use. Also, a questionnaire, consisting of the demographic characteristics and risk factors, as the possible modes of transmission  was completed for each patient.According to the manufacturer's instructions, RNA was extracted from 100 µL of plasma, using the AccuPrep Viral RNA Extraction Kit . About 5 mL of peripheral blood was kept in EDTA-containing tubes and then the PBMCs were isolated, using Ficoll-Hypaque density gradient centrifugation . The PBMCs were then washed three times with phosphate-buffered saline (pH = 7.3±0.1) and counted and then RNA was extracted from a pellet of approximately 3-5 × 106 PBMCs, using the RNA Virus Mini Extraction Kit . The final volume, in the reaction for synthesis of cDNA, was 20 µL, including 5 µL RNA, 1 µL random hexamer , 6.5 µL of diethylpyrocarbonate (DEPC) treated water, 4 µL reverse transcriptase reaction buffer 5x, 2 µL dNTP, 10 mM stock, , 0.5 µL RNase Inhibitor  and 200 IU of Moloneymurine leukemia virus reverse transcriptase , which was then incubated at 65°C for 5 minutes, 25°C for 10 minutes, 42°C for 60 minutes and 70°C for 10 minutes.2 (AB), 0.5 mM of each dNTPs (AB), HCV-speciﬁc primers, and AmpliTaq DNA polymerase (AB). The amount of specific-HCV primers in each reaction based on the type of primer was different. Extension reactions consisted of initial denaturation at 94°C for 20 seconds, followed by 30 cycles of 94°C for 20 seconds, 64°C for 20 seconds, and 72°C for 35 seconds. The reaction was performed using 750 Real-time PCR . Genotyping was confirmed by sequencing with gold standard methods therefore we sent several samples for sequencing and results were compared with other sequences in GenBank by the GeneScan 3.1 software.RNA was isolated from plasma and PBMC specimens as described above. HCV genotype was determined using type-speciﬁc primers and the protocol described previously . BrieflyAnalysis was performed using the Statistical Package for Social Sciences (SPSS) software version 17.0, using descriptive values such as mean, standard deviation and Fisher’s exact probability test. P value < 0.05 was considered statistically significant.One hundred and thirty seven patients with positive chronic HCV were enrolled in the present study. Injection drug being the major risk factor (in injection drug users (IDUs)) was detected in 94 (71.5%) patients, blood transfusion was found in 23 (16.7%) patients and the cause of infection was unclear in 20 (14.5%) patients. The mean age of patients was 41.3 ± 11.6 years (range: 21-68). Of the 137 patients, 113 (82.5%) were male. The most common genotype in the study population was subtype 3 for plasma (57.7%) and PBMCs (51.1%), followed by subtype 1a in plasma (36.5%) and PBMCs (30.7%). Genotype 2 and 1b were mixed with genotype 1a and 3a whereas genotype 4 was not detected in samples. Subtype 3 was the most frequent genotype in patients over 40 years of age (47.3% versus 42.4%) and subtype 3 was the most frequent in patients under 40 years old (46.5% versus 34.9%). subtype 3 was more frequent (42.8%) in male cases. It should also be noted that the difference in the distribution of the genotypes between males and females was statistically significant . Also the most common genotype in HCV in IDUs population was subtype 3, which was more significant than the other subtypes . HCV types in plasma and PBMCs of all patients were analogous except for 17 patients (12.4%). In four patients no genotype was detected in the plasma but genotype 3 was detected in PBMCs. Detailed information on these patients is shown in This study was done on 137 infected chronic patients to trace the frequency of HCV infection in their plasma and PBMCs. In former studies there has been evidence of persisting HCV RNA in PBMCs despite sustained clearance of HCV RNA from serum , 25. TheHowever since liver biopsy is invasive, therefore all of patients must provide informed consents. Furthermore, we postulated which of these cases had occult HCV and determined that the therapy strategy is important. These patients had HCV RNA in PBMCs persistence, which may lead to HCV reactivation or further relapse after stopped interferon treatment at 24-48 weeks and under special conditions such as immunosuppression. These individuals require more monitoring after the end of treatment of antiviral therapy. Herein tracing of HCV RNA in the plasma before therapy is sufficient and PMBCs specimens can provide supplemental information when considering the therapy strategy. In our study the frequency of mixed HCV infection was determined as approximately 3.7% in plasma and 7.3% in PBMC these results are similar to other study from Iran . Mixed i


Systemic lupus erythematosis (SLE) is an inflammatory disorder associated with significant morbidity and mortality. Kidneys are frequently affected in SLE and various stages of lupus nephritis have been identified based on severity of the disease. Treatment varies with the staging and correct diagnosis is essential for timely intervention as it can have significant impact on morbidity and mortality. The objective of the study was to determine whether laboratory parameters of lupus nephritis (LN); including urinalysis, serum creatinine (S. Cr) and 24 hours urine protein can accurately predict histologic staging of the disease.This retrospective study was conducted in department of Nephrology, Liaquat National Hospital Karachi from January 2012 to December 2014. Fifty one patients of SLE who underwent renal biopsy were selected. Patients, urinalysis at the time of renal biopsy, serum creatinine and 24 hours urine collection for protein were noted. All patients renal biopsy was read by the same pathologist. Patients were clinically staged based on these parameters and their histologic staging based on biopsy findings were compared, to see their correlation. Data was analyzed using SPSS version 17. Chi-square test was used to analyze categorical data and p<0.05 was considered significant. Cohen’s kappa (κ) analysis was used to examine the agreement by comparing lupus nephritis staging done by laboratory and histological ground. P value <0.05 indicates that agreement was unlikely due to chance alone.Among 51 patients analyzed, 37 patients were females (72.5%) and 14 patients were males (27.5%) with mean age of 32.51 + 16.91 years. In stage II, kappa (κ) of 0.304 represented fair strength of agreement and a p value of 0.012 (p<0.05)which was statistically significant. In stage III, kappa was 0.209 indicating none to slight agreement and a p value of 0.131 (p>0.05). In stage IV, kappa (κ) was 0.141 (slight agreement)and p value 0.301 (p>0.05) in stage V; kappa (κ) of 0.030 represented poor agreement and a p value of 0.828 (p>0.05).Staging of lupus nephritis done on basis of laboratory findings did not correlate well with underlying histological staging. Therefore, renal biopsy is an essential tool in approach to lupus nephritis in order to provide timely and appropriate treatment to patients. Systemic lupus erythematosis (SLE) is an inflammatory disorder that affects virtually all organs of the body. It is associated with significant morbidity and mortality. Mainstay of treatment of SLE is based upon preventive measures as early detection can significantly change the outcome of the disease. Kidneys are frequently affected in SLE. The earliest manifestation of renal involvement being an abnormal urine sediment, with proteinuria being the most frequent abnormality.4The incidence of lupus nephritis is high in Asians ranging between 33%-55%.11We conducted this study to see if clinical renal parameters could predict the histologic staging and if renal biopsy could be avoided and treatment decision could be taken based on clinical grounds.After informed consent and ethical committee approval of the hospital conducting the study, retrospective analysis of all patients with SLE that underwent renal biopsy between January 2012 and December 2014 was done. The study was conducted in department of Nephrology, Liaquat National Hospital Karachi. We studied 51 patients of lupus nephritis. SLE was diagnosed with a positive ANA and anti dsDNA. Patient’s demographic characteristics, urine analysis at the time of renal biopsy, serum creatinine and 24 hours urine collection for protein was noted. Patients clinical staging based on these parameters is shown in Urinalysis was done for the presence or absence of proteinuria, hematuria or both. Proteinuria was positive if urine dipstick was positive for protein, Hematuria was defined as RBC > 5 RBC/HPF. Serum creatinine of >1.2mg/dl was considered abnormal for females and creatinine of >l.4mg/dl was considered abnormal for males. 24 hours urine collection for protein was considered nonnephrotic if protein was 300- 2999 mg/24 hours in urine and > 3 gm /24 hrs protein was considered nephrotic. Staging based on Histology is shown in All patients with SLE of both gender who underwent renal biopsy, and had serum creatinine, urinalysis and 24 hours urine protein measurements were included.Patients were excluded if SLE patients renal biopsy had inadequate specimen and diagnosis was inconclusive. In addition if any of the laboratory parameter was missing that patient was excluded from the study. Patients already on immunosuppressant or anti-proteinuric medication and patients who had other concomitant disease other than lupus nephritis on renal biopsy were also excluded.Data were collected on pre designed Performa, and analyzed using SPSS version 17. Chi-square test was used to analyze categorical data and p<0.05 was considered significant. Cohen’s kappa (κ) analysis was used to examine the agreement between two diagnostic methods i.e. clinical parameter and histologic finding on renal biopsy with values ≤ 0 as indicating no agreement, 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement. P value <0.05 indicates that agreement was unlikely due to chance alone.Total 51 patients were enrolled based on inclusion and exclusion criteria. Among 51 patients analyzed, 37 patients were females (72.5%) and 14 patients were males (27.5%) with mean age of 32.51± 16.91 years. Expected staging of lupus nephritis done on laboratory parameters showed 08 patients in stage II(15.6%), 14 patients in stage III (27.4%),20 patients in stage IV(39.2%), 9 patients in stage V(17.6%) and none of the patient was expected to have either stage I or VI on laboratory parameters. Histological classification of stages showed 3 patients of stage II(5.9%), 11patients of stage III(21.5%), 26 patient of stage IV (50.9%), 10 patient of stage V(19.6%) and 01 patient of stage VI(1.9%). No patient had stage 1 on renal biopsy. Twenty eight patients had renal insufficiency in our study (54.9%) while 23 patients (45.1%) had normal renal function. Minimum proteinuria was found to be 72mg/24hr and maximum proteinuria was 8000mg/24hr.We applied kappa analysis to measure agreement by comparing lupus nephritis staging done by laboratory and histological ground. The level of agreement between diagnostic methods indicates level of accuracy of diagnosis. Results are shown in In stage II, kappa (κ) of 0.304 represented a fair strength of agreement and a p value of 0.012(p<0.05) which was statistically significant. In stage III, kappa was 0.209 indicating none to slight agreement and a p value of 0.131 (p>0.05); stage IV kappa (κ) was 0.141(slight agreement) and p value of 0.301 (p>0.05). In stage V; kappa (κ) of 0 .030 represented poor agreement and a p value of 0.828(p>0.05).Overall kappa analysis showed only poor to fair strength of agreement for different stages of lupus nephritis(0.030-0.304). Although only in stage II, p-value was <0.05 indicating statistically significant that there is a relation between clinical renal parameters with renal biopsy while in rest of other stages it showed no significant relation.In addition, further analysis revealed that out of 8 patients considered to have stage II lupus nephritis on their laboratory parameters, when compared to their histopathology results, it was only matched with 2 patients (25%) while 3 patients (37.5%) were in stage V, 2 (25%)were in stage III and 1 patient (12.5%) was in stage IV on biopsy report.Similarly, for stage III lupus nephritis, 05 (35.7%) out of 14 patients, laboratory and histopathology results were matched. One patient (7.14%) was found to have stage II, 7 patients (50%) were in stage IV and 1 patient (7.1) was in stage V lupus nephritis on histopathology results.There were 20 patients labeled stage IV lupus nephritis on laboratory parameters. Among them 12 (60%) patients histopathology report found the same stage while 3 patients (15%) were in stage III, 4 patients (20%) were in stage V and 1 patient (5%) labeled stage VI on biopsy report.Nine patients labeled stage V on laboratory parameters were compared with their histopathology findings, only 2 (22.2%)patients results were matched while 6(66.6%) were in stage IV and 1 (11.1%) was in stage III.This indicates the fact that it is inadequate to rely on laboratory impression solely for starting treatment and renal biopsy should be performed in all cases of SLE having any urinary abnormality.Lupus nephritis has varied clinical presentation. Urinary abnormalities especially proteinuria is the cardinal feature of the disease. 25% of patients may have abnormal urine sediment at the time of diagnosis and 60% will develop some abnormality during their illness.14Several case series have demonstrated that significant renal damage may be present without clinical signs of renal involvement in advanced staging of lupus nephritis.18Our study is an eye opener, as patients with SLE are usually treated by Rheumatologists and they follow clinical renal parameters to diagnose staging of lupus nephritis. In a survey done at JHUSOM, involving rheumatologists 37% would not refer the patient to a nephrologist with proteinuria <1000mg/24 hours and 17% would not refer even in the presence of hematuria.19We did not considered C3 levels and anti-ds DNA titers as they may influence the clinical staging, since studies have suggested that these parameters are indicative of proliferative stages. In addition, it is limited by a small sample size, but still the results are significant and need further studies as it may have a very important role in preventing long term renal outcome.Staging of lupus nephritis done on basis of laboratory findings did not correlate well with the underlying histopathological staging, and therefore, renal biopsy is an essential tool to approach lupus nephritis in order to provide timely and appropriate treatment to patients. We advocate early renal biopsy in all patients with LN, regardless of degree of proteinuria or renal function.