To assess differences in demographics, treatment and outcome of lean (LD) compared to overweight and obese people with diabetes clinically classified as type 2 diabetes mellitus (T2DM).2, ≥25–30 kg/m2 and ≥30 kg/m2 aged 30 to 50 years were compared, including demographics, cardiovascular (CV) risk factors, comorbidities and outcomes.We combined data from the German DIVE  and DPV (Diabetes-Patienten-Verlaufsdokumentation) databases to produce a large cohort of people with T2DM. The characteristics of people with Body Mass Index (BMI) <25 kg/m2. LD reported more nicotine and alcohol consumption compared to overweight and obese people. More LD were treated with insulin in comparison to the other subgroups . Regression models adjusted for age, gender and diabetes duration showed a 2.50 times higher odds ratio (OR) for hypoglycemia and a 2.52 higher OR for mortality in LD compared to the BMI subgroup ≥30 kg/m2.A total of 37,870 people were included in the analysis, 3,191 of these (8.4%) had a BMI < 25 kg/mLD is associated with an increased risk of hypoglycaemia and death. Patients are characterized by male gender, lifestyle habits as smoking and alcohol consumption while cardiovascular comorbidities are less important. In comparison to patients of the other weight groups they are treated with insulin more often and considerably less with metformin. In previous studies, percentages of these lean diabetic participants ranged from 7.5% to 21% [2 [The majority of patients with type 2 diabetes mellitus (T2DM) are obese or overweight. Few studies have investigated the subgroup of patients with a clinical diagnosis of type 2 diabetes and a low to normal body mass index (BMI) < 25 kg/m kg/m2. I% to 21% , whereaso 21% [2 . Accordio 21% [2 .The aim of our analysis was to characterize participants with the phenotype of lean type 2 diabetes mellitus (T2DM), their diabetes therapies and outcomes compared to overweight and obese participants in the DIVE and DPV databases consisting of participants from Germany.Data were obtained from the DIVE  registry and the DPV (Diabetes-Patienten-Verlaufsdokumentation) database. The DIVE registry was established in Germany in 2011 –13. PatiIndividuals with a clinical diagnosis of T2DM and aged 30 to 50 years, documented in DPV until September 2016 and in DIVE until December 2016 were included in the present analysis. Participants who tested positive for beta- cell autoantibodies were excluded . Moreover, patients with low body weight as a consequence of wasting diseases such as malignancies, tuberculosis, alcoholism or chronic pancreatitis were also excluded from the DPV dataset. Because of technical reasons this was not possible for centers with the DIAMAX software.Data regarding age, gender, BMI, blood pressure, CV risk factors , lifestyle factors , CV history, history of comorbidities and current comorbidities (during the most recent treatment year) were collected. In addition, details of diabetes therapy were documented. Hypercholesterolemia was defined as total cholesterol ≥ 200 mg/dl, LDL-cholesterol ≥ 160 mg/dl, HDL-cholesterol <40 mg/dl, triglycerides ≥ 150 mg/dl or medication with lipid lowering drugs. Coronary heart disease (CHD) was defined as a previous myocardial infarction or history of angina pectoris, hypertension was defined as blood pressure levels >140 mm Hg systolic or 90 mm Hg diastolic and/or receiving antihypertensive drugs, and being physically active less than once a week was considered as a sedentary lifestyle.Categorical variables are presented as percentages. Continuous variables are presented as means with standard deviations (s.d.). Unadjusted comparisons were conducted using chi-squared test for binary and Kruskal-Wallis test for continuous variables. Logistic regression was performed to evaluate odds ratios for being a lean patient with type-2 diabetes and for CV risk factors, history of comorbidities, current comorbidities and death, respectively. Number of deaths may be underreported due to documentation based on diabetes practices. Data are given as unadjusted odds ratios (ORs), and adjusted for age, sex and diabetes duration. A two-sided P- value < 0.05 was considered statistically significant. Statistical analysis was performed using SAS version 9.4.2 (7.7). The mean (s.d.) duration of diabetes was 3.2 years (11.6). CV risk factors were highly prevalent, in particular obesity (49.8%), hypertension (59.9%), dyslipidemia (78.6%) and a sedentary lifestyle (85.1%).A total of 37,870 participants (42.5% women) were included in the present analysis ; 12,809 2, 9,234 (31.7% women) to the subgroup with BMI ≥25- <30 kg/m2 and 25,445 (44.4% women) to the subgroup with BMI ≥30 kg/m2 (2 (60.0% vs. 55.6%). CV risk factors were less prevalent in the lean BMI subgroup: hypertension in 35% and hypercholesterolemia in 78.0%. Concerning lifestyle, there were significantly more smokers  and participants with alcohol consumption over 20 g per day in the lean BMI subgroup  while sedentary lifestyle was equally distributed between the subgroups . Macrovascular comorbidities as acute coronary syndrome (ACS), history of myocardial infarction and history of peripheral artery disease (PAD) (ACS: 2.9% vs. 3.9% and 3.7% (P = 0.045), MI: 2.2% vs. 3.3% and 2.9% (P = 0.002), PAD: 6.1% vs. 5.9% and 6.7% (P = 0.046) were reported less frequently in the lean BMI subgroup while history of stroke was equally distributed in all subgroups. However, chronic kidney disease (CKD) as a manifestation of microvascular comorbidity was more prevalent in the lean BMI subgroup .A total of 3,191 (8.4%) participants (40.8% women) were assigned to the lean subgroup of participants with BMI <25 kg/m30 kg/m2 , There wHbA1c differed statisticly significant with 8.03% in the lean body weight group, 7.99% and 8.02% in the overweight and obese subgroup. Fasting blood glucose was significantly higher with increasing BMI subgroup. However, both differences in parameters of glucose metabolism seem to be clinically insignificant. Lipid profile was more favorable in the lean body mass group .2 were metformin and insulin. While the percentage of metformin therapy increased significantly with increasing BMI , more participants with BMI <25 kg/m2 were treated with short and long acting insulin in comparison to the other subgroups   . Sulfony2. Current smokers and participants with alcohol consumption ≥ 20 g had OR (CI) of 1.42  and 1.93 , respectively. Interestingly, macrovascular comorbidities and comorbidities known as cardiovascular risk factors showed lower odds ratios as predictors for belonging to the lean BMI subgroup. Acute coronary syndrome and myocardial infarction had an OR (CI) of 0.78 , history of myocardial infarction had an OR of 0.75 , hypertension 0.29  and dyslipidemia 0.41 .The adjusted multivariable logistic regression analysis  showed t2 . Regression models adjusted for age, sex and diabetes duration showed a 2.50 times higher risk of hypoglycemia for lean participants compared to those with BMI ≥ 30 kg/m2 , stroke 1.00  or amputation 1.36  . Hypogly30 kg/m2 . After aIn our cohort the subgroup of lean diabetes (8.4%) is smaller compared to previous studies –5 while In the lean diabetes group were significantly more smokers than in the other body weight groups. This is in accordance with numerous cross-sectional studies, that indicate that body weight, or body mass index , is lower in cigarette smokers than in nonsmokers –21 A recConcerning alcohol consumption 12% of lean diabetes patients but only 6.6% of the obese patients reported drinking more than 20g alcohol per day. This is higher than reported by the Chicago study, where the authors discuss an underreporting of alcohol consumption. But in accordance to the Chicago study in our study alcohol consumption is reported twice-fold higher in lean compared to obese patients . For a lBlood glucose control, measured by HbA1c and fasting blood glucose differed statistically but not clinically significant between the different weight groups.These findings are different to the findings described in the Chicago study group, were lean participants showed worse blood glucose control compared to obese. In the DIVE/DPV cohort, we looked not only for differences in metabolic control but also for differences in hypoglycemia, with lean participants reporting significantly more hypoglycemic events. The lean participants had significantly better lipid profile butwith mean LDL-cholesterol of 119.7 mg/dl t treatment targets of < 70 mg/dl as recommended by ESC/EAS were not achieved even in lean patients . This is2, metformin was prescribed only in 27.1%, significantly less compared to the other subgroups. While initially metformin was recommended by some guidelines only for overweight or obese participants with type 2 diabetes, since 2005, metformin is now the recommended first-line treatment independent of body weight [2 only 52.2%, were treated with metformin though HbA1c targets of <7% were not reached. Percentage of metformin usage in our cohort is in discordance to data from primary care in the UK, where in 2013, metformin prescribing was noted in 83.6% of the participants (95% CI 83.4% to 83.8%) [Main antidiabetic drugs used in our study cohort were metformin and insulin. In lean participants with BMI <25 kg/my weight , 47. Mety weight . Thus ito 83.8%) . On the o 83.8%) . In our The typical lean participant with type 2 diabetes in our analysis was male, normotensive, and a current smoker with increased alcohol intake. Unhealthy lifestyle habits as higher prevalence of smoking and alcohol consumption in diabetic patients may have contributed to adverse effects and lead to higher risk of all-cause mortality in our cohort as described in the literature , 51.Analysis of events during the most recent treatment year showed no significant differences for macrovascular complications between lean and obese subgroups. However, participants with lean body weight had an OR of 2.43 for hypoglycemias compared to participants of the overweight subgroup.2 vs. >25 kg/m2 (OR 1.39 (1.00–1.93), as well as patients with advanced age (>75 years vs. ≤ 75 years), cognitive dysfunction, and nephropathy, hospitalized in internal medicine wards had higher risks of hypoglycemic events [The association between lean body weight and risk of hypoglycemia is also described in the Italian FADOI-DIAMOND study. In this study of patients with type 2 diabetes with BMI ≤ 25 kg/mc events . In a rec events . In a rec events . Analysec events .While ric events . In our c events . The assc events . Of courc events –61. Simic events . In concThe main strength of our study was the large number of participants included which was possible by analyzing data from two big German registries. We chose the age group between 30 and 50 ages to exclude participants with juvenile diabetes and on the other hand, participants with low BMI due to frailty and sarcopenia in older age. It was possible to exclude participants with a history of chronic and wasting diseases, which are strong confounders of body weight and mortality from DPV but not from the DIVE database. Analyzing participants with diabetes in the age between 30 and 50 years with lean phenotype as in our study implicates the risk to include up to 20% of patients with LADA . FortunaIn our analysis, lean participants with type 2 diabetes had higher mortality and an increased risk of hypoglycemic events. Use of metformin is recommended in guidelines but reported only in a minor part of lean patients while treatment strategies often included insulin, which is associated with increased hypoglycemia. Higher prevalence of smoking and alcohol consumption in these participants may also contribute to adverse effects and lead to higher risk of all-cause mortality seen in our cohort. The most appropriate treatment target in lean T2DM is reduction in mortality and cardiovascular risk. Although smoking cessation, alcohol reduction, physical activity, metformin, statins and angiotensin converting enzyme inhibitors have shown their efficacy to reduce cardiovascular mortality. Treatment strategies for lean participants with T2DM should therefore be multimodal with lifestyle modification, antihypertensive therapy, lipid lowering therapy and antihyperglycemic therapy avoiding hypoglycemia and insulin therapy, where possible.


Association of thyroid dysfunction (TD) with interferon treatment of HCV is well known to clinicians. However, a few studies have highlighted the role of hepatitis C virus per se in the development of TD. The aim of this study was to know the prevalence of TD in non-interferon treated HCV infected patients referred for thyroid function testing.4, FT3, and TSH were determined by radioimmunoassay method. Among 557 ELISA-positive HCV patients 446  were selected for this study. Serums FTp = 0.648). Hyperthyroidism and subclinical hypothyroidism were slightly more common in female and overall hypothyroidism and overt hypothyroidism in male patients but the difference was not statistically significant (p > 0.05). The incidence of TD was relatively high in patients above 36 years (median age) but the difference was not statistically significant either collectively or in gender base groups (p > 0.05). TD was detected in 15.2% of patients: 9.0% hypothyroidism and 6.3% hyperthyroidism. In increasing order subclinical hypothyroidism, overt hypothyroidism, overt hyperthyroidism, and subclinical hyperthyroidism were found in 4.7%, 4.3%, 3.6%, and 2.7% patients, respectively. Overall TD was more common in female than in male HCV patients but the difference was not significant (16.1% versus 12.4%;  Prior to interferon treatment, HCV infection itself causes biochemical thyroid dysfunction in 15.2% of local HCV patients. According to the World Health Organization 3 to 4 million people are newly infected with HCV every year and there are about 180 million patients infected with HCV in the world . These ipatients . A signireatment –8. The preatment . Recentlreatment  and has reatment .Pakistan is second after Egypt where prevalence of hepatitis C is alarmingly high. Currently about 10 million people in Pakistan are infected with HCV infection . A large4 and TSH concentrations with or without FT3 determination. In these patients serums FT4 and FT3 were determined by radioimmunoassay (RIA) and TSH was estimated by IRMA techniques using commercial kits of Immunotech Inc. . RIA and IRMA batches were run with commercially derived control sera at low, medium, and high concentrations which were included in every run. All assays were carried out in duplicate. Measurement of radioactivity, fitting of the standard curve, and analysis of samples were carried out using a computerized gamma counter . RIA and IRMA results were expressed at less than 10% CV of imprecision profile.History and laboratory records of all HCV ELISA-positive patients referred for thyroid testing to CENUM, Mayo Hospital, during January 2013 to December 2014 were reviewed. Among them such patients who were already diagnosed for thyroid diseases and taking thyroid medications or had thyroid surgery were excluded. Similarly HCV patients previously treated with interferon were also excluded. We selected those patients whose serum samples were analyzed for both FT4, FT3, and TSH, as standardized in our laboratory, are 11.0–22.0 pmol/L, 2.5–5.8 pmol/L, and 0.3–4.0 mIU/L, respectively. Hyperthyroidism was classified if serum TSH was ≤0.1 mIU/L and FT4 > 22.0 pmol/L and as subclinical if serum TSH was ≤0.1 mIU/L and FT4 ≤ 22.0 pmol/L. Hypothyroidism was considered as overt if TSH > 4.0 mIU/L and FT4 < 11.0 pmol/L and as subclinical if TSH > 4.0 mIU/L and FT4 ≥ 11.0 pmol/L. The analysis of data was carried out using Microsoft Excel program on a personal computer. Chi-square and Student t-test were applied to test the significance of difference between two arbitrary groups. A p value of less than 0.05 was considered significant.Normal ranges for FTn = 107) or due to combination of FT3 and TSH (n = 4). In selected patients both serums FT4 and TSH were determined with or without additional determination of FT3. As serum FT3 was determined in only 95 (21.3%) patients we excluded this parameter from data analysis. Among selected patients 341 were female and 105 male patients. Their mean (±SD) age was 37.1 ± 11.1 years with age range between 10 and 90 years and was comparable in male and female patients . Analysis of thyroid function tests showed that 378 (84.7%) patients had serum TSH level within normal range (0.3–4.0 mIU/L) and were euthyroid. Among the rest of the patients with abnormal TSH , 40 (9.0%) had hypothyroidism and 28 (6.3%) had hyperthyroidism. Further subgrouping of HCV patients having thyroid disorder revealed that, in increasing order, 21 (4.7%) patients had subclinical hypothyroidism, 19 (4.3%) patients had overt hypothyroidism, 16 (3.6%) patients had overt hyperthyroidism, and 12 (2.7%) had subclinical hyperthyroidism. 4 and TSH in euthyroid, hypothyroid, and hyperthyroid HCV patients. Compared to euthyroid patients serum FT4 concentration was significantly lower in hypothyroid and higher in hyperthyroid patients (both p < 0.001). Likewise serum TSH concentration was significantly higher in hypothyroid and lower in hyperthyroid as compared to euthyroid HCV patients.Among 557 ELISA-positive newly diagnosed HCV patients 446 were selected for this study. The remaining patients were excluded either due to determination of TSH alone (p = 0.648). Hyperthyroidism  and subclinical hypothyroidism was slightly more common in female as compared to male HCV patients. However, in none of them was the difference statistically significant. Only overall hypothyroidism and overt hypothyroidism were more frequent in male HCV patients but the difference was not statistically significant (p > 0.05). Thyroid swelling was detected in 19 (5.6%) patients and all of them were females. The incidence of TD was significantly higher in these women as compared to those women presenting without goiter . Seven among them had TD . However, excluding these goitrous women from analysis slightly reduced the incidences of hypothyroidism (8.8% to 8.7%) as well as hyperthyroidism (7.3% to 6.2%) but statistical difference remained comparable (p > 0.05) between female and male HCV positive counterparts.The gender base difference in incidence of TD is elaborated in p > 0.05) either collectively or in gender base groups.The age range in our patients was 10–90 years and the median age was 36 years. To elucidate the role of patient age in incidence of TD, patients were divided on the basis of median age. The aim of this study was to know the prevalence of thyroid dysfunction in interferon-naive HCV patients referred to CENUM, Mayo Hospital, for thyroid function testing. Our results showed that thyroid dysfunction was detected in 15.2% of the HCV patients. This figure is in accordance with studies carried out in other countries reporting thyroid dysfunction in 7% to 15% untreated HCV patients –8, 17. AThe prevalence of TD in general population is around 5% with more incidence of hypothyroidism compared to hyperthyroidism , 20. AccMost studies have reported higher incidence of TD in female HCV patients as compared to male patients because of high incidence of thyroid autoimmunity in female patients , 25. In We also investigated incidence of TD in HCV patients of different age groups. It was observed that incidence of thyroid dysfunction was relatively high in patients above 36 years of age but was not statistically more as compared to younger patients. This was true for both male and female HCV patients. This finding is supported by other studies , 27 that3 determination in a few patients, and incomplete medical information like liver enzyme and biopsy status. Recently an association between liver dysfunction and thyroid hormone has been elucidated in HCV patients [Limitations of this study are its cross-sectional nature, comparatively low number of male patients, serum FTpatients –30. Besiα therapy is being planned. Thyroid disease need not be a contraindication to IFN-α therapy; early detection of subclinical or overt thyroid disease may allow uninterrupted continuation of IFN-α treatment. However, periodic monitoring of TD patients should be performed during therapy.In conclusion HCV infection, independent of interferon treatment itself causes biochemical thyroid dysfunction in 15.2% of local patients without age and gender consideration. In Pakistan, local studies have reported TD in 20% of HCV patients after IFN-alpha and ribavirin treatment , 31. It


Aquilaria malaccensis Lam, commonly known as Agarwood, is a highly valuable species used in production of agar oil from its infected wood, which is utilized in pharmaceutical and perfumery industry. Agar oil formation in agarwood takes years through the natural process which is induced by natural or artificial injury or microbial infection. The role of soil fungi and bacteria in artificial induction is still an unexplored area. In the present study, we isolated the fungal and bacterial community residing inside the stem of A. malaccensis tree and circumventing soil, samples collected from 21 different sites of the north-eastern state Assam of India and explored their potential in induction of Agarospirol -2-propanol) production by artificially infecting the trees with these microorganisms. A total 340 fungi and 131 bacteria were isolated from 50 stem samples, and 188 fungi and 148 bacteria were isolated from 50 soil samples. Highest Shannon (H′ = 2.43) and Fisher (α = 5.57) diversity index was observed in the stem isolates. The dominant fungal genus was Trichoderma in stem with Pi value of 0.18; while in soil, Aspergillus showed dominance with Pi value 0.73. In bacteria, Bacillus genera showed dominance in both stem and soil samples with Pi = 0.62 and 0.51, respectively. Forty fungal and bacterial isolates were used to assess their potential to induce formation of agarwood in A. malaccensis by artificial infection method. Gas chromatography mass spectroscopy (GC-MS) analysis confirmed development of Agarwood by the presence of Agarospirol compound in samples collected after 3 months of the artificial infection. Only 31% of bacterial and 23% of fungal isolates showed their ability in production of Agarospirol by artificial infection method. Bacteria Pantoea dispersa and fungi Penicillium polonicum showed the highest production in comparison to other isolates. Aquilaria malaccensis is an oleoresin-producing tree which occurs in Malaysia, Myanmar, Sumatra, Borneo Island, Philippines, Bangladesh, Vietnam, China, and India  of wild fauna and flora , 0.5 μL of dNTP mix , 2.5 μL of ITS1, ITS4 for fungi, and 518F and 1492 R primers for bacteria (10 picomole/μL), 1 μL of DNA template, and 0.5 μL of Ampli Teg Gold (5 U/μL). The ITS1, ITS4, 518F, and 1492 R primers were synthesized from Merck nucleotide synthesis services, Bengaluru, India, according ITS1 5′TCCGTAGGTGAACCTGCGG3′, ITS4 5′TCCTCCGCTTATTGATATGC3′, 518F 5′-CCAGCAGCCGCGGTAAT-3′, and 1492R 5′-GGYTACCTTGTTACGACTT-3′ sequence. The Polymerase Chain Reaction was done on Veriti Thermal Cycler (Applied Biosystem) using following programmes: initial denaturation at 94°C for 2 min; 30 cycles of denaturation, annealing, and elongation at 94°C for 1 minute; 57°C for 1.30 min, and 72°C for 2 min followed by final elongation at 72°C for 4 min. The negative control was also run using sterile water. The amplified product was checked on 1.5% agarose gel by gel electrophoresis. The amplified product was sequenced by Merck sequencing services, Bengaluru, India.The genomic DNA of pure fungal isolates was extracted using DNeasy Plant mini kit  by following the manufacture's instruction. Bacterial DNA was isolated using the CTAB method  of the US National Centre for Biotechnology Information (NCBI), SILVA and UNITE databases. The sequences were submitted to NCBI database. The phylogenetic tree was developed using Neighbor-Joining and Maximum Likelihood method by MEGA 6.0 software using sequence alignment by Clustal W pairwise sequence Alignment tool of the EMBL Nucleotide Sequence Database. The evolutionary distances were computed using the Maximum Composite Likelihood method.A. malaccensis was determined by the Shannon diversity index, Simpson's index, and Fisher Alpha index. Species richness of the isolated microbes was estimated according to the Menhinick's index (Dmn) by the following equation , where “Dmn” denotes species richness. A species was explained as dominant if Pi > 1/ Dmn, where Pi represents the relative abundance of a species, i explains the total number of competing species in the community , Simpson's index, and Fisher Alpha index were calculated by SPADE programme version 3.1  in the trunk of the tree. The initial hole was made 20 cm above from the ground and next wound was drilled at 10 cm interval and the depth of the drill was 1.5 cm. Around 1 ml of homogenized microbial culture was inoculated in each hole using sterile syringe and hole was covered with para film. Each strain was infected in replicates. A sterilized medium was used as a syringe control.Forty microbial isolates selected on the basis of their dominance were screened for their potential to induce agarwood formation by artificial infecting the wood with these micobes. For this, fungal mycelium was grown on PDA media and 5 days old fungal plugs were transferred to 100 ml of potato dextrose broth. The cultures were incubated at 25°C for 7 days. While, bacterial cultures were grown in 100 ml of nutrient broth medium and incubated for 48 h at 37°C. The grown fungal biomass was collected by filtration with Whatman filter paper no 1 and bacterial biomass with centrifugation at 8,000 rpm for 10 min and lyophilized to get powder form. The lyophilized sample was transported in sterile falcon tubes at experimental site. The inoculum was developed in 10 ml of 2% glucose solution. The artificial infection was done in The wood samples (~2–3 g) were collected 3 months after inducing artificial infection by drilling the wood around the inoculated hole. The collected of infected wood dust sample (1 g) were extracted in ethyl acetate by the reflux method. Uninoculated wood dust (wood control) and media control wood dust (syringe control) were also treated in similar manner to compare chemical composition with treated wood dust samples. The extract was concentrated in rotary evaporator. The concentrated extract was dissolved in 1 mL of dichloromethane and analyzed by Gas Chromatography-Mass Spectroscopy (GC-MS)  using an DB-WAX capillary column  and using Helium (purity > 99.999%) as the carrier gas with the constant flow rate of 1.0 mL/min. Around 1 μL of injection volume was used. The temperature of injector part was 230°C and oven temperature programing was used. The initial oven temperature was maintained at 80°C for 1 minute, then increased to 150°C @ 10°C/min in 7 min followed by temperature increase to 250°C @ 5°C/min till 22.5 min. The Mass Spectroscopic system was operated in EI mode (70 eV). Mass of the compounds was analyzed in the range of m/z 50–500 amu.Unscrambler version 10  was used to perform Principal Component Analysis (PCA) and statistical analysis.3). It was observed that in the stem five fungal classes viz. Eurotiomycetes, Dothideomycetes, Zygomycetes, Saccharomycetes, and Sordariomycetes represented fungal community, while in the soil samples only four out of the five classes were present. Saccharomycetes were not isolated from stem samples. In the case of bacteria Bacilli class was dominant in the stem and soil samples.Actionbacteria and Alpha Proteobacteria members were obtained only from the stem and Beta Proteobacteria only from the soil samples.In all 340 fungi and 131 bacteria were isolated from 50 stem samples, and 188 fungi and 148 bacteria were isolated from 50 soil samples. These isolates were grouped on the basis of similarity of their external morphology and microscopic examination and representative isolates were used for molecular identification by 16s rRNA region amplification using 518F and 1492 R primers for bacteria and ITS region amplification using ITS1 and ITS4 primers for fungi and sequenced using Merck sequencing services, Bengaluru, India. Distribution of fungi and bacteria up to class level is given in Figure Meyerozyma guilliermondii AQGWD10 showed less distant from Lasiodiplodia sp. cluster in N-J method while, in M-L method M. guilliermondii showed close to Pichia sp.  and Maximum Likelihood (M-L) method Figures , 4. Both. Figure . In the The phylogenetic relation of these isolates is given in the Figures A. malaccensis in the North Eastern part of India was measured using Shannon diversity index (H′), Simpson index (D), and Fisher alpha index (α). Species richness in each source was measured by the Menhinick's diversity index (Dmn). The diversity index for all samples were measured by SPADES software and presented in Table Dmn = 0.034) followed by soil (Dmn = 0.02). A similar pattern was measured in bacteria also (stem = 0.03 and soil = 0.02). Source-specific fungal dominance by Camargo's index was the highest measured in soil (47.00) followed by stem (29.57) and bacterial dominance also observed the highest in soil (49.33) than stem (37.43). The dominant genus was Tricoderma in stem with their Pi = 0.18, while in soil Aspergillus showed dominance with Pi = 0.73. The next dominance genus was Lasiodiplodia (Pi = 0.13) and Fusarium (Pi = 0.12) in stem and Alternaria (Pi = 0.15) in soil. Rests of fungal species were less dominant <0.09. In bacteria, Bacillus genera showed dominance in both root and soil samples with Pi = 0.62 and 0.51, respectively. Pseudomonas was dominant in the stem and Lysinibacillus in soil with Pi = 0.10 and 0.09, respectively. The Pielou's evenness index showed the distribution of fungal and bacterial species evenly in soil (J′ = 0.18 and 0.25) and stem (J′ = 0.42 and 0.25). The Maximum Shannon diversity index was observed for stem fungal isolates (H′ = 2.43) accompanied by soil bacteria (H′ = 1.25), while the Simpson diversity index was the highest in soil bacteria (H′ = 2. 84) followed by stem bacteria in comparison to fungi. Fisher alpha (α) was measured the highest in fungal stem (α = 5.57), followed by fungal soil (α = 1.70) samples. The similarity of fungal and bacterial isolates from stem and soil were done using heat map expression. It is observed that stem and bacterial isolates showed less variation at genera level and creating a cluster in heat map , followed by fungi Penicillium polonicum (3.33%), Syncephalastrum racemosum, Penicillium aethiopicum, and Trichoderma asperellum  agarospirol was detected only in artificially infected wood samples. It is reported that the presence of agarospirol is one of the responsible compound for fragrance in agarwood . While Mohamed et al.  among 18 different bacterial species in Aquilaria sp. of Malaysia region.Endophytes play an important role in plant physiology. Most of the endophytes are helpful in host plant growth, stress tolerance, and explained as the microorganisms that are not detrimental to the plant  and fungi Penicillium polonicum (3.33%) within 3 months only, after inducing the infection. The agarospirol is one of the responsible compounds for fragrance in Agarwood. The use of such microbes in artificial production of agarospirol could be source of economic development of villagers of North Eastern part of India.Endophytes are helpful in plant physiology by producing different compounds, which assist in plant growth, stress tolerance, and plant immunity. Isolation and identification of such microbes are an important aspect for biotechnological applications. In present study, we could isolate total 528 fungi and 279 bacteria from Aquilaria stem and surrounding soil samples collected from different sites of Assam. Bacilli were found most dominant class in the bacteria and Sordariomycetes in fungi. In stem, Hypocreaceae was measured most dominant fungal family with 23.8% richness while Bacileaceae was dominant bacterial family with 62.6 and 59.5% richness in both stem and soil isolates. Maximum Shannon diversity index was measured in stem fungal isolates (H′ = 2.43). Agarospirol production was induced successfully using bacteria Conception and designed the experiments: HC and NK. Performed the experiments: HC. Analyzed the data: HC and NK. Contributed reagents/materials/analysis tools: HC and NK. Wrote and enriched the literature: HC and NK. Corrected the manuscript: NK.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Aim. To determine pregnancy and delivery outcomes among teenagers. Materials and Methods. An 8-year retrospective comparative hospital-based cohort study is analysing singleton pregnancy comorbidities and delivery parameters of a teenage group under the age of 20 compared with a young adult group 20–24 years of age in a university hospital. Results. Teenage is a risk factor for preterm birth <37 weeks (1.21 [1.08–1.35]), foetal growth restriction (1.34 [1.21–1.48]), episiotomy (1.27 [1.21–1.34]), uterine revision (1.15 [1.06–1.25]), APGAR <7 at 1 min (2.42 [1.21–1.67]), cephalopelvic disproportion (1.26 [1.07–1.48]), and postpartum haemorrhage (1.42 [1.25–1.62]); however, caesarean delivery occurs less frequently in teenagers than in adults (0.75 [0.70–0.80]). The following comorbidities are risk factors for teenage pregnancy (risk ratio [CI 95%]): anaemia (1.13 [1.10–1.17]), low urinary tract infection (1.10 [1.03–1.18]), pediculosis (2.42 [1.90–3.00]), anogenital condyloma (1.50 [1.04–2.17]), and trichomoniasis (1.74 [1.12–2.68]). The risks for hepatitis B and hepatitis C, premature rupture of membranes, and placenta praevia were lower compared with those in the young adult group, respectively, 0.43 (0.26–0.71), 0.90 (0.85–0.96), and 0.29 (0.20–0.41), while the risk for gestational diabetes and preeclampsia were the same in both groups. Conclusion. Considering the high risks for teenage pregnancy, this information should be provided to pregnant adolescent women and their caregivers. The World Health Organization (WHO) defines teenage pregnancy as pregnancy in which the mother is under the age of 20 at the time the pregnancy ends . About 1Complications occurring during pregnancy and labour represent the second most frequent cause of death in teenagers 15–19 years of age. The babies born to this age group are at a higher risk of dying than those born to women 20 to 24 years of age [, and the rate of births  was 1.40%, the highest in the world according to these statistics.In the study of Sedgh et al., based on United Nations Statistics Division's Demographic Yearbook data , RomaniaThe socioeconomic factors are important for the prognosis of teenage pregnancies, as has been shown in a previous article published by this team .The aim of this study was to compare pregnancy and delivery outcomes among adolescent women with those of young adults in a tertiary maternity centre, by focusing on the influence of medical factors.This is a retrospective comparative hospital-based cohort study of all singleton pregnancies and deliveries that occurred in a teenage group (<20 years old) compared with a young adult group (aged 20–24 years old) at “Cuza Voda” Hospital, Iasi, Romania, which is the reference centre for the region of northeastern Romania. Inclusion criteria for all cases and controls were singleton pregnancy, age < 25 years, gestational age at delivery > 24 weeks, and delivery between January 1, 2007, and December 31, 2014. The ethics committee of the hospital approved this study. We extracted data from the hospital's electronic database for the following two parameters: pregnancy comorbidities and parameters concerning delivery, using the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes.χ2) and Fischer exact tests for expected frequencies <5. We evaluated pregnancy and delivery outcomes for most maternal and neonatal outcomes, estimating the risk ratios (RRs) and 95% confidence intervals (CIs). p < 0.05 indicated statistical significance.We compared obstetric characteristics of the two age groups, analysing the frequency of data by using the chi-square , and we compared both subgroups of teens with the control group (20–24 years of age).All analyses were conducted using SPSS 17.0 , and data were charted using Microsoft Excel for Windows 2010.n = 3,961, 8.19%) involved teenagers (<20 years of age).A total of 48,308 deliveries were registered between January 2007 and December 2014 at the University Maternity Hospital “Cuza Voda.” A small number of them  were included in this study. The singleton pregnancies were divided into two groups: pregnant teenage women  and, as the control group, pregnant women 20–24 years old .Of the total deliveries, only singleton pregnancies  or for preeclampsia (p = 0.45). The number of cases of eclampsia was too small to interpret.Registered comorbidities are presented in p = 0.18). Instead, the incidence of anaemia and lower urinary tract infections was higher in adolescents compared with that in young adults . Diabetes and obesity were more common in young adults than in the teenage group .Foetal anomalies detected at birth did not occur more frequently in the teenage group (p < 0.01), as did anogenital warts (p = 0.03) and trichomoniasis (p = 0.02). Hepatitis B and hepatitis C were more common in adults (p < 0.01). Premature rupture of membranes and placenta previa occurred more frequently in teenagers  and , resp.). We could not establish a correlation between the presence of chorioamnionitis and patient age (p = 0.27).Regarding infections associated with pregnancy, pediculosis occurred more frequently in the teenagers than in the control group , but this correlation does not exist for very low birth weight foetuses < 1,500 g (p = 0.35). We also found a correlation between foetal growth restriction and teenage age at delivery (p < 0.01).The birth weight of the foetuses is also affected by the age of the mother. A good correlation exists between low birth weight < 2500 g and maternal age < 20 years (p < 0.01). On the other hand, episiotomy was more common in adolescents (p < 0.01).Caesarean delivery was more common in the adult group than in the adolescent group . Cephalopelvic disproportion and breech presentation were more common, as expected, in the teenage group , but humeral presentation (p = 0.28) did not appear more frequently in a certain age group.Perineal ruptures of 3rd and 4th degrees, cervical lacerations, and instrumental deliveries with forceps and vacuum extractor had no statistical correlation with a particular age group (p < 0.01).Postpartum haemorrhage as well as uterine revision proved to be more common in the teenage group (p < 0.01). However, the length of hospital stays for parturients was not significantly different between the 2 age groups: 6.44 ± 3.89 days for teenagers versus 6.59 ± 4.23 days for young adults (p = 0.06).Adolescent births had more cases of Apgar < 7 at 1 minute than adult births had . In turn, Shah et al. [In our study, with the exception of genital warts and trichomoniasis, we could not find an association between teen pregnancy and bacterial vaginosis,a et al.  and Sagia et al. ), whereah et al.  reportedInfections with hepatitis B and hepatitis C viruses were higher in the control group, as reported by Kurth et al. .Our results are in accordance with almost all studies that found higher risks of preterm birth , 16, 19,Shrim et al.  reportedThe same consideration is applicable to the birth weight of foetuses. There is a good correlation between low birth weight < 2,500 g and maternal age < 20 years, but this correlation does not exist for very low birth weight foetuses < 1,500 g.Concerning the modality of labour, our findings suggest a lower risk of caesarean and operative vaginal delivery in women < 20 years of age compared with those between 20 and 24 years of age.These results regarding caesarean delivery support the results of other published findings , 20, 21;A lower risk for instrumental delivery has been cited by many authors , 13, 15,p < 0.01) and ). Sagili et al. [Concerning postpartum haemorrhage and manual/instrumental uterine revision, we found a higher incidence in the teenage group  and fewer adult controls (n = 736) [In 2015, a study was conducted in a different geographic region of the country  covering a shorter period of time (2011-2012) with fewer teenage pregnancies (n = 736) . It focu Gardnerella, Candida, E. coli, Streptococcus, Staphylococcus, or Klebsiella. Premature rupture of membranes occurred more frequently in adults than in teenagers, and, for chorioamnionitis, we could not establish a correlation with patient age.Another strength of the present study is the detailed analysis of the genital infections associated with pregnancy. One of the mechanisms for preterm birth is the high frequency of genital infections enhancing local prostaglandin levels: few studies have examined the infections associated with pregnancy , 24. In The other mechanisms described by Shrim et al.  for pretn = 50) to be able to stratify the adolescent pregnancy and delivery outcomes on subgroups by age, to better evaluate the effect of mother's age on pregnancy and birth finality. Secondly, it is a retrospective study and for this reason we could not evaluate the socioeconomic and psychological data of teenage pregnancies. Another limitation of the study is that testing for genital infection by chlamydia, as a potential risk factor of preterm birth, was not performed.This research has some limitations. First, this is a relatively small sample size of early adolescence (<15 years old) , and foetal distress.Our data about delivery may reassure obstetricians that teen births have a caesarean delivery and an instrumental birth risk lower than that in adults, so that labour in < 20 year olds may be treated similarly to that in adult women, and that decisions about operative intervention should not be based on age alone.However, despite the findings of other studies, we found a high incidence of postpartum haemorrhage and of manual or instrumental uterine revision in the teenage group compared with the young adult group.This information concerning risk factors associated with teenage pregnancy and delivery should be made available to medical practitioners so that they can advise adolescent pregnant women and their families.


The study was conducted on 50 subjects irrespective of age and sex divided into two groups i.e. Group-A comprising 20 normal healthy controls while Group-B consisted of 30 patients of NHL with bone marrow infiltration. Bilateral bone marrow trephine biopsy was done to assess the patterns of bone marrow infiltration. Serum β2m and LD2 isoenzyme levels were determined in already diagnosed 30 patients of NHL. The values were compared with 20 healthy age and sex matched controls. Correlation coefficients were determined using Pearson’s Correlation Coefficient. The estimations were made prior to the institution of chemotherapy.β2m and LD2 levels were significantly  raised in NHL patients with disease advancement and were compared with controls. These serological markers showed negative correlation (-0.235 for β2m and -0.133 for LD2) with the spread of disease and patterns of involvement in NHL patients.By observing the patterns of bone marrow involvement in NHL patients possible guidelines about prognosis and treatment protocols can be obtained as the serological markers levels correlate well with the spread of disease and patterns of involvement in NHL patients. Lymphomas represent clonal malignancies of lymphoreticular system in which the majority of the cells are frozen at a single stage of normal differentiation.2Cancer is a group of over 100 diseases, all of which start with the growth of abnormal cells. Instead of dying in the normal cell life cycle, cancerous cells continue to divide into new abnormal cells, and grow out of control.52m reflects the tumor load and LD indicates invasive potentials of lymphoma.8Histological patterns can be assessed on the sections of trephine biopsies. Any of the three patterns i.e. interstitial, focal and diffuse can be seen either alone or in combination.2m is a low molecular weight polypeptide, non-covalently linked to the heavy chain of class 1- histocompatibility antigens which are shed with cell turnover. It is plentiful on the surface of lymphocytes. Increased production or destruction of the cells cause β2m levels in the blood to increase.11βThis study was conducted to investigate the patterns of bone marrow involvement in NHL patients and to correlate these patterns with β2m and LD2 levels in these patients.It was a cross sectional study conducted on 50 subjects irrespective of age and sex divided into Group A comprising 20 normal healthy controls and group B consisting of 30 patients of NHL with bone marrow infiltration.The following formula was used for estimating the sample size.With following Assumptions:P1 = Expected Prevalence of infiltration of NHL with bone marrow=12.4%P2 = Expected Prevalence of infiltration of NHL without bone marrow=30%|p2-p1| A significance criterion of 5% (0.05) and a power of 80% (0.80) were chosen.Level of Significance= α= 5%α/2= for 95% confidence level =1.96ZPower of the Test= 1-β=80%α/2= 80% power of study = 0.84ZHence, the minimum sample size is calculated as below.n =Total Sample Size: 50 patientsThe total no. of subjects  was distributed into two groups for inferential statistics.Number of control patients = 20Number of NHL patients = 30Total number of patients = 50The sample size for two groups was designed as under:Controls (Group A): In this group 20 Normal healthy subjects (controls) were enrolled.Group B: In this group 30 patients of NHL with bone marrow were enrolled.Non-probability, purposive sampling technique was used.The cases were selected from Lahore General Hospital, Lahore, Institute of Nuclear Medicine and Oncology (INMOL), Lahore, Services Hospital, Lahore and Mayo Hospital, Lahore.Newly diagnosed cases of NHL by lymph node biopsy prior to the institution of chemotherapy of both sexes and all age groups were selected for the present study. The patients with the history of myocardial infarction, renal failure, hepatic dysfunction, skeletal muscle disease, hemolytic anemia, malignancy of any other system, cerebrovascular accident, Infectious mononucleosis and intestinal infarction were excluded.Bilateral bone marrow trephine biopsy was done bilaterally from right and left posterior superior iliac spine to assess the patterns of bone marrow infiltration. Among serological markers β2m was estimated by Enzyme Linked Immunosorbent Assay (ELISA). LD2 was measured by Agarose Gel Electrophoresis at Centre of Excellence in Molecular Biology (CEMB), Lahore. The results were analyzed by using Student’s ‘t’ test with 95% confidence level. P-value < 0.05 was taken statistically significant. The statistical methods were used to calculate arithmetic mean, standard deviation, probability ‘P’ value, correlation and using Pearson’s Correlation Coefficient. These calculations were carried out using SPSS V16.0.Informed verbal consent was taken prior to the interview. The respondents were informed about the purpose of the study. The confidentiality of the information was ensured and maintained.In NHL patients diffuse pattern of bone marrow infiltration was the commonest being observed in 14 (46%) cases followed by interstitial infiltration in 10(33%) cases. In the focal variety, paratrabecular pattern was present in 4(13%) patients while random type was observed in 2(6%) cases . As boneIn patients with diffuse pattern mean β2m level was 4.2 ± 0.84, in interstitial was 3.87 ± 0.49 while paratrabecular and random had 3.47 ± 0.28 and 3.05 ± 0.07 µg/ml respectively and the LD2 values in diffuse, interstitial, paratrabecular and random pattern were 55.07 ± 2.97, 52.1 ± 4.99, 48.5 ± 5.06 and 45.5 ± 6.36% respectively .Comparing β2m and LD2 levels among controls and Bone Marrow infiltration NHL patients was statistically highly significant  with negative correlation values for β2m and LD2 was -0.235 and -0.133 respectively .In NHL patients diffuse pattern of bone marrow infiltration was the commonest being observed in 14 (46%) cases followed by interstitial infiltration in 10 (33%) cases. In the focal variety, paratrabecular pattern was present in 4(13%) patients while random type was observed in 2(6%) cases. The diffuse pattern was seen in 9 cases unilaterally and in five cases bilaterally. As regards interstitial pattern it was observed unilaterally in seven cases and bilaterally in three cases while paratrabecular pattern was seen in three cases unilaterally and in one case bilaterally. Random pattern was observed in two cases unilaterally. In the present study markedly raised levels of serological markers i.e.β2m and LD2 were associated with the diffuse pattern, in particular. Similar observations were reported by Mora, Miyashita and Yoo C.As regards patterns of lymphoma infiltration the commonest was diffuse infiltration with marked increase in β2m and LD2 levels followed by interstitial, paratrabecular and random patterns. According to Ding D, Wu L, Yoo C and Rotaru IJeongThe design of our study was cross-sectional i.e., one point in time, so for better observation and proper understanding of the patterns of bone marrow infiltration in NHL patients with β2m and LD2 levels, cohort study should be designed and followed.By observing the patterns of bone marrow involvement in NHL patients, possible guidelines about prognosis and treatment protocols can be obtained. The serological markers correlate well with the spread of disease and patterns of involvement in NHL patients.NM: Conceived, designed and did statistical analysis & editing of manuscript.NA: Reviewed article critically for intellectual content.ZI: Did review and final approval of manuscript.First author takes the responsibility for intellectual integrity of this study.


Background: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts.Methods: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria.2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%.Results: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χConclusion: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months. Malignant middle cerebral artery (MCA) infarction accounts for approximately 10% of all patients who present with ischemic stroke with a mortality rate up to 80% . DecomprEarly critics documented the poor functional outcome of DC, particularly with dominant hemisphere involvement, resulting in a higher percentage of surviving patients who were dependent on caregivers, increasing their burden. In addition, the surgical complications and the cosmetic malformations were undesirable. Neurosurgeons may be hesitant to perform this procedure due to the lack of literature available on functional outcomes after DC. Recently, the pooled analysis of three small randomized trials (RCTs) showed that decompressive craniectomy can decrease mortality and morbidity associated with malignant infarction of the MCA . Three r of the MCA region with space-occupying cerebral edema and mass effect on non-contrasted computed tomographic (CT) imaging of the brain. Pretreatment clinical evaluation was based on the Glasgow Coma Scale (GCS). Inclusion and exclusion criteria are shown in Table A longitudinal cohort study of patients diagnosed with malignant MCA territory infarction admitted to the neurosurgery department of Shifa International Hospital, Islamabad, Pakistan between July 2015 and November 2016 was performed. Data were collected from patients' medical, surgical, and radiological imaging records. A total of 125 patients between the ages of 18 and 65 years were included in this study. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria . MalignaWe collected data, such as age, sex, past medical history, distribution of the infarction, affected hemispheric dominance, National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and modified Barthel Index (mBI) scores. Informed consent was taken from patients before participation in the study. Approvals from the institutional review board and ethical committee of Shifa International Hospital, Islamabad, Pakistan were obtained for this cohort study .The outcome on follow-up was analyzed during outpatient department (OPD) visits in the stroke clinic and/or telephonically at three, six, and 12 months. Patients' outcomes were defined by rating the activities in their daily life with measurements established in stroke research by the mRS, NIHSS, and mBI. The mBI score of ≥ 60 and an mRS score of 3 or less were taken as favorable outcomes characterized by minimal-to-moderate disability, whereas an mBI less than 60 and an mRS of 4–6 define poor outcomes with moderately severe or very severe disability .Sample size calculation was done using power and sample size calculation software , with a Data from a total of 34 patients was reviewed and analyzed. Out of these, 31 were selected while three were lost to follow-up. Twenty of the 31 patients (64.5%) were males while 11/31 (35.5%) were females. The mean age of all patients was 51.61 ± 13.96 years. The mean time to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had right middle cerebral artery infarcts (RMCAI) and 13 (41.9%) had left middle cerebral artery infarcts (LMCAI). The total hospital mortality rate was found to be 3/31 (8.7%). The mean duration of hospital stay was 15.5 ± 11.5 days. The mean number of days spent in intensive care unit (ICU) was 4.00 ± 2.58  had dysarthria and 11/31 (35.5%) had aphasia. After one month, 16/31 (51.6%) had dysarthria and 10/31 (32.3%) had aphasia. After three months, 6/31 (19.4%) had dysarthria and 5/31 (16.1%) had aphasia. After six months follow-up, 4/31 (12.9%) had dysarthria and 2/31 (6.4%) had aphasia. Changes of upper and lower limb motor power with the passage of time are shown in Figure Logistic regression was applied to assess the association between the type of MCA infarct with mRS, GCS, NIHSS, modified Barthel Index, and upper and lower limb motor power. The logistic regression model was not statistically significant χ2 4) = 3.896, p = 0.866. Pair-sample T-test was done to assess for any change in neurological score and upper and lower limb motor power at admission and six months after discharge. There was a statistically significant improvement of neurological scores and upper and lower motor power over a course of six months after treatment (p < 0.001) with poor functional outcomes (mRS > 4 and mBI > 60) . No statistically significant relationship was found between time to surgery and duration of hospital stay . One-way analysis of variance (ANOVA) was applied to look for an association between the time from diagnosis to surgery and language impairment, and it showed no significant association . Of the three patients that expired, two were males and one was female. Among the expired patients, one patient had a right-sided MCA, whereas the other two had left-sided MCA cerebral infarcts. All three patients had an mRS at admission of 5 and a mean GCS of 7.67 ± 2.082.The imperative role of DC in the survival of patients with malignant MCA infarction is widely accepted. Several randomized controlled trials have demonstrated a decrease in mortality of patients undergoing DC -13. HoweOne of the striking findings of our study is the considerable improvement in the motor power of both upper and lower limbs, but more so in the lower limbs. Carter, et al. concluded that the one-year outcome in the majority of their patients was noted to be at the level of near-independence, being able to walk, and having a Barthel score greater than 60 . We expeOur results comply with other studies, including a meta-analysis by Foerch, et al. According to that study, there was a considerable decrease in the mortality and improvement of functional outcome after DC as compared to the conservative management of malignant MCA infarct. However, it was still associated with an increased incidence of major disability (mRS score: 4-5) among the survivors . FurtherNeuropsychological evaluation of the patients could not be carried out on follow-up. Previous literature shows some depressive inclination in patients after undergoing the surgery . The proDecompressive craniectomy shows mild improvements in functional outcomes after six months of malignant MCA infarcts but with poor functional outcomes as a whole (mRS > 4 and mBI < 60). An early diagnosis is essential for DC, which has been shown to reduce mortality.


To evaluate the performance of the Sensitire MYCOTB MIC Plate (MYCOTB) which could measure the twelve anti-tuberculosis drugs susceptibility on one 96-wells plate.gyrA for Ofx and Mfx; rpoB for RFP and Rfb; embB for EMB; rpsl for Sm; katG and the promoter region of inhA for INH, ethA and the promoter region of inhA for Eth. The sequence results were compared with results of MYCOTB and APM to analyze the consistency between sequence results and MYCOTB or APM.A total of 140 MDR-TB strains and 60 non-MDR strains were sub-cultured and 193 strains were finally tested for drug resistance using MYCOTB and agar proportion method (APM) and another 7 strains failed of subculture. The drugs included ofloxacin (Ofx), moxifloxacin (Mfx), rifampin (RFP), amikacin (Am), rifabutin (Rfb), para-aminosalicylic acid (PAS), ethionamide (Eth), isoniazid (INH), kanamycin (Km), ethambutol (EMB), streptomycin (Sm), and cycloserine(Cs). The categorical agreement, conditional agreement, sensitivity and specificity of MYCOTB were assessed in comparison with APM. For strains with inconsistent results between MYCOTB and APM, the drug resistance related gene fragments were amplified and sequenced: The categorical agreement between two methods for each drug ranged from 88.6% to 100%. It was the lowest for INH (88.6%). The sensitivity and specificity of MYCOTB ranged from 71.4% to 100% and 84.3% to 100%, respectively. The sensitivity was lowest for Cs(71.4%), EMB at 10μg/ml (80.0%) and INH at 10.0μg/ml (84.6%). The specificity was lowest for Rfb (84.3%). Overall discordance between the two phenotypic methods was observed for 96 strains, of which 63 (65.6%) were found susceptible with APM and resistant with MYCOTB and the remaining 33(34.4%) strains were resistant by APM and susceptible with MYCOTB. 34/52 (65.4%) sequenced APM susceptible and MYCOTB resistant(APM-S/MYCOTB-R) strains had mutations or insertions in the amplified regions. 20/30 (66.7%) sequenced APM resistant and MYCOTB susceptible strains had mutations in the sequenced genes. MICs of twenty-nine of these thirty isolates were equal to or within 1 doubling dilution of the critical concentration.MYCOTB had good performance for most of tested drugs and could be used as an alternative to the more labor demanding and longer turnaround time solid culture based DST method for detection of drug susceptibility in China. A national drug resistance survey done in China in 2007 showed that 5.7% of new and 25.6% of previously treated TB cases were MDR, and 0.5% and 2.1% respectively were XDR[ mutant) . Another mutant) .The clinician sometimes may use higher dose of medicines for patients with isolated strains with quantitative result indicating a borderline susceptible as for the fluoroquinolone .MIC resuA total of 140 MDR-TB strains isolated during national drug resistance survey in 2007 and 60 non-MDR strains with other drug resistance patterns preserved in National Reference Laboratory were recovered on Löwenstein-Jensen medium (L-J medium). 193 strains were finally tested using the 7H10 Agar Proportion Method (APM) and the MYCOTB assay.Mycobacterium tuberculosis to anti-tuberculosis drugs. Critical concentrations for each drug were as follows: 2.0μg/ml for ofloxacin (Ofx), 0.5μg/ml and 2.0μg/ml for moxifloxacin (Mfx), 1.0μg/ml for rifampin (RFP), 4.0μg/ml for amikacin (Am), 0.5μg/ml for rifabutin (Rfb), 2.0μg/ml for para-aminosalicylic  5.0μg/ml for ethionamide (Eth), 0.2μg/ml and 1.0μg/ml for isoniazid (INH), 5.0μg/ml for kanamycin (Km), 5.0μg/ml and 10.0μg/ml for ethambutol (EMB), 2.0μg/ml and 10.0μg/ml for streptomycin (Sm) and 25.0μg/ml for cycloserine (Cs). All media were used within 2 weeks of preparation. Agar plates were incubated at 37°C for 3 weeks before interpretating results[7H10 agar media containing critical concentration (CC) drugs were prepared in house according to the Clinical and Laboratory Standards Institute (CLSI) methods for indirect testing of susceptibility of g results.−4 dilution of standardized strain suspension when conducting drug susceptibility testing by agar proportion method can give countable colonies and verified that the bacterial concentration was within the targeted amount(∼105 CFU/ml). 100ul bacterial suspension was transferred to the MYCOTB plate wells containing the antibiotics. Plate was covered with the seal and incubated at 37°C and monitored by specified plate reader at days 10 after inoculation. If the growth of control well is poor after 10 days incubation, the plate will be incubated again for additional 4 days or 11 days until the growth control can be visible. The suspensions in all wells were checked after 24 hours and 48hours incubation and before reading results at the end of incubation for contamination. The MIC were determined only when all wells in plates were clear and not contaminated. For each drug, the lowest concentration with no visible growth was considered to be the MIC.MYCOTB tests were performed according to the manufacturer’s instructions. A loop of freshly grown bacilli were scraped from the surface of L-J medium and added to saline-tween-80 solution with glass beads, homogenized through vertex and adjusted to a 0.5 McFarland standard using the Sensititre Nephelometer. 100ul suspension was transferred to 11 ml of Middlebrook 7H9 broth supplemented with oleic acid-albumin-dextrose-catalase (OADC). Vortex for 30 seconds. The control agar medium with inoculum of 10gyrA for Ofx and Mfx; rpoB for RFP and Rfb; embB for EMB; rpsl for Sm; katG and the promoter region of inhA, ethA and the promoter region of inhA for Eth (www.ncbi.nlm.nih.gov/BLAST) for comparison with the corresponding genes of the M. tuberculosis strain H37Rv.For strains with inconsistent susceptibility results between MYCOTB and APM, two methods were firstly repeated and if the results were different between the initial and repeated tests, the test was repeated again. For strains with inconsistent results after repeats, we amplified the drug resistance related gene fragments and sequenced them by the methods reported previously ,8,9,10 f for Eth . The seqThe definitions of categorical agreement were referenced as in the study conducted by Jongseok et al.. BrieflyIn the analysis of the data, APM was used as the reference standard for calculating categorical agreement, conditional agreement, sensitivity and specificity of the MYCOTB assay for each drug. All of data were analyzed using Microsoft Excel.Among 193 strains, the proportion of resistant isolates by drug were 11.9% for Ofx, 11.4% and 1.6% for Mfx at 0.5μg/ml and 2.0μg/ml, 69.9% for RFP, 4.7% for Am, 53.9% for Rfb, 5.7% for PAS, 15.0% for Eth, 78.2% and 67.4% for INH at 0.2μg/ml and 1.0μg/ml, 4.7%for Km, 19.7% and 2.6% for EMB at 5.0μg/ml and 10.0μg/ml, 48.7% and 35.2% for Sm at 2.0μg/ml and 10.0μg/ml, 3.6% for Cs. The proportion of MDR was 69.9%.The categorical agreement, conditional agreement, sensitivity and specificity of MYCOTB for all drugs are shown in Overall discordance between the two phenotypic methods was observed for 96 strains, of which 63 (65.6%) were found susceptible with APM and resistant with MYCOTB and the remaining 33(34.4%) strains were resistant by APM and susceptible with MYCOTB. A total of 74 strains had discrepant results for Ofx, Mfx(0.5μg/ml), RFP, Rfb, Eth, EMB(5.0μg/ml), Sm(2.0μg/ml), Cs and PAS. 17.6% (13/74) strains were APM-resistant but MYCOTB-susceptible (APM-R/MYCOTB-S) and 82.4% (61/74) strains were APM-susceptible but MYCOTB-resistant (APM-S/MYCOTB-R). Of note were that twenty (90.9%) strains were APM-R/MYCOTB-S and two (9.1%) were APM-S/MYCOTB-R among 22 discrepant strains for INH at high level concentration (1μg/ml). DNA was amplified and sequenced from 82 strains with discrepant results for the following drugs: Ofx, Mfx, RFP, Rfb, Eth, EMB, Sm and INH except 14 strains with inconsistent result for Cs and PAS. Sequencing results for strains with discrepant results between the two methods are shown in gyrA gene. For RFP, 4/4 strains had mutations or nucleic acids deletion in the rpoB gene. For Rfb, 13/14 (93%) strains had mutations in the rpoB gene. 5/11 (46%) strains with APM-S/MYCOTB-R for EMB had embB mutation. For INH at 1.0μg/ml, two strains were both wild type for katG and the promoter region of inhA. 1/3 strains had mutation in the rpsL gene. 2/6 strains had mutations in the ethA gene.65.4% (34/52) APM-S/MYCOTB-R strains had mutations or insertions in the amplicated regions in the resistance related genes. For Mfx at 0.5 μg/ml and Ofx, 5/7 (72%) and 4/5 (80%) strains had mutations in the gyrA gene and the MIC was 0.5μg/ml, which was equal to the low-level critical concentration (0.5μg/ml). 2/3 strains had mutations in the rpoB gene and MICs for these 3 strains were all 0.5ug/ml, which were equal to Rfb critical concentration. Only 1/5 APM-R/ MYCOTB-S strains had mutations in the rpsL gene for Sm. The MIC range of the 5 stains was 1.0–2.0ug/ml which were well below or equal to the critical concentration. One Eth APM-R/MYCOTB-S strain occurred mutation in the promoter region of inhA and the MIC was equal to the critical concentration of Eth. 15/20 discordant strains for INH at 1.0μg/ml had mutations in katG or the promoter of inhA genes.66.7% (20/30) APM-R/MYCOTB-S strains had mutations in the resistance related genes. For Mfx at 0.5 μg/ml, the strain had a mutation in the China has a serious epidemic of drug-resistant tuberculosis. Cheap, effective and rapid detection of drug resistance to tuberculosis is very important for patient management and TB control. The common used solid medium based proportion DST method in China was labor demanding and need at least 4–6 weeks for result interpretation. The method used one or two critical concentrations to determine qualitative susceptibility or resistance. However, some studies reported that the heterogeneous MIC levels observed in drug resistant M. tuberculosis strains may have important therapeutic implications ,14,15,16Mycobacterium tuberculosis in China. We did not measure turnaround time but most of MYCOTB test results were available in 10 to 14 days, which was shorter than the reporting time in agar medium (3 weeks) or L-J medium (4 -6weeks). We found that the categorical agreement between the two methods was ≥90% for eleven drugs, only not for INH at 1.0μg/ml (88.6%). The sensitivities or specificities were below 90% for Rfb (84.3%), for INH at 1.0μg/ml (84.6%) and for EMB at 10.0μg/ml (80.0%). As with previous studies[katG gene, six strains had mutations(C-15T) in the promoter region of inhA gene and 5 strains were both wild type for katG and the promoter of inhA genes. For Cs the sensitivity was only 71.4%. The results in study of Jongseok et al[ and that in Yu’s study[In this study we showed the usefulness of the 96-well plate assay for testing of drug susceptibility of s studies,18, our r medium  weeks ors studies, the “coeok et al showed teok et al. Howeveru’s study. Some stu’s study,21. ThusembB gene. For Eth, 2/6 strains had mutation causing amino acid change in the ethA gene. MYCOTB thus showed better agreement with sequencing results than APM for Ofx, Mfx, RFP, Rfb, but not for EMB at 5μg/ml and Eth. Brossier’s study reported that only 46.8% (22/47) Eth resistant isolates mutated in ethA[ethA gene can not explain all mechanisms of Eth resistance. In Bakula’s study, sequence analysis of the EMB resistance determining region (ERDR) in the embB gene was not sufficient for rapid detection of EMB resistance, and mutations in codon 306 were not good markers of resistance to EMB[thyA and PAS resistance was limited [In the present study, most of the discrepant results for Ofx, Mfx, RFP, Rfb, Eth and EMB were APM susceptible and MYCOTB resistant. DNA sequencing of genes known to be responsible for resistance to these drugs resolved these discrepancies in favor of the MYCOTB plate for four of the above mentioned five drugs except for EMB: Ofx (4/5), Mfx (5/7), RFP (4/4) and Rfb (13/14). For EMB at 5μg/ml, nearly half (5/11) of the strains carried mutations in the ly 46.8% /47 Eth rce to EMB. A studyce to EMB showed t limited , so we dIn the present study, we used APM as reference method. The reasons that we choose APM method but not MGIT method as reference were as following, 1) critical concentrations for Rfb and Cs for MGIT method were not recommend by WHO. 2) APM method contained two critical concentrations for both low level and high level resistance for INH, EMB, Mfx and Sm. 3) When the critical concentration differed between the APM breakpoint and the MGIT 960 breakpoint, the accuracy was superior when the APM breakpoint was used for all drugs except for INH and PAS as Heysell et al reported. Other cThere are some limitations for the present study. The first limitation was that the numbers of strains resistant to Am, Km and especially Cs were low (less than 10) resulting to low precision for the sensitivity calculation, and so further validation study was necessary for these drugs. The second limitation was that the mechanisms of resistance for Cs and PAS were not clear and the genotypic or other phenotypic methods were not conducted to resolve the discrepancy between APM and MYCOTB assay. The last one was that we did not inoculate the strain suspensions on blood agar for exclusion of contamination. The step of subculture on blood agar to check for fast growing non-tuberculosis mycobacteria and/or bacterial/fungal contamination was necessary for MYCOTB assay. In the present study, the preserved pure Mycobacterial tuberculosis strains but not clinical strains were used for the assessment and we therefore roughly checked the plate for contamination after 24 and 48 hours of incubation. If the MYCOTB assay will be used for clinical diagnosis, the step of inoculation suspensions on blood agar for exclusion of contamination is absolutely essential.sl at the moment is the only real rapid test for second-line drugs. However, MTBDRsl can not replace conventional drug susceptibility due to the low sensitivities for detection of resistance of kanamycin (42.7%-43.1%), capreomycin (71.4%-90.6%) and ethambutol (56.2%-77.3%) and the limited number of drugs it tests for[Nucleid acid amplication based Genotype MTBDRtests for,27,28. I


Atypical hemolytic uremic syndrome (aHUS) is a devastating disease with significant morbidity and mortality. Its genetic heterogeneity impacts its clinical presentation, progress, and outcome, and there is no consensus on its clinical management.To identify the characteristics of aHUS in Turkish children, an industry-independent registry was established for data collection that includes both retrospective and prospective patients.CFH, CFI, MCP, CFB, C3, DGKE, and CHFR5 genes, underlying genetic abnormalities were uncovered in 34 patients (80.9%). Sixty-one patients (41.7%) had extrarenal involvement. During the acute stage, 33 patients (22.6%) received plasma therapy alone, among them 17 patients (51.5%) required dialysis, and 4 patients (12.1%) were still on dialysis at the time of discharge. In total, 103 patients (70.5%) received eculizumab therapy, 16 of whom (15.5%) received eculizumab as a first-line therapy. Plasma therapy was administered to 84.5% of the patients prior to eculizumab. In this group, renal replacement therapy was administered to 80 patients (77.7%) during the acute period. A total of 3 patients died during the acute stage. A total of 101 patients (77.7%) had a glomerular filtration rate >90 mL/min/1.73 m2 at the 2-year follow-up.In total, 146 patients  were enrolled; 53 patients (36.3%) were less than 2 years old at initial presentation. Among the 42 patients (37.1%) whose mutation screening was complete for The Turkish aHUS registry will increase our knowledge of patients with aHUS who have different genetic backgrounds and will enable evaluation of the different treatment options and outcomes. CFH, CFI, MCP (CD46), or CFH-CFHR genomic rearrangements) and components of the alternative pathway C3 convertase (i.e. C3 and CFB) or anti-complement factor H autoantibodies are identified in 60–70% of patients with aHUS  vs. 18.6 mL/min/1.73 m2 ; P = 0.019). At the last follow-up visit, the GFR of 68 of the patients (66%) was >90 mL/min/1.73 m2. Eculizumab-related side effects were reported in 2 patients: an allergic reaction in 1 patient, and convulsions and sepsis after eculizumab administration in 1 patient. No patient relapsed while receiving eculizumab therapy.In this registry population, 103 patients (70.5%) received eculizumab therapy . The median age at diagnosis in this group of patients was 3.4 (IQR 1.2–7) years, and the median follow-up duration was 2.05 (IQR 1.1–3.2) years. Eighty patients (77.7%) underwent renal replacement therapy during the acute period. Plasma therapy was administered to 84.5% of the patients prior to the initiation of eculizumab, and 16 patients (15.5%) received eculizumab as a first-line therapy. Complete hematologic and renal remission was achieved in 82.2% and 76.3% of the patients, respectively. Median follow up duration was 2.05 years (IQR 1.1-3.2 years) for this group. During the follow-up period, eculizumab treatment was discontinued in 52 patients (51.5%) for various reasons . Five patients (4.8%) with severe renal disease did not respond to therapy and progressed to ESKD. The initial median eGFR of these patients was significantly low when compared with the eGFRs of the rest of the patients (7.6 mL/min/1.73 mn = 1), intractable seizures (n = 1), and multisystem involvement (n = 1). Three patients died during the follow-up period. A total of 10 patients were lost to follow-up, and outcome data were available for the remaining 130 patients . At their last follow-up visit, 13 patients had undergone treatment for ESKD . More than 75% of the patients had a GFR >90 mL/min/1.73 m2 . Patients aged younger than 2 years accounted for 36.3% of the population in our study, which was significantly lower than the corresponding percentages reported in the global and French registries  . A totalExtra-renal involvement in aHUS can significantly impact patient prognosis. Neurologic involvement is the most frequent complication, which can occur in 8–30% of the patients . In our CFH mutations were the most commonly identified abnormalities [MCP mutations and C3 mutations were the most common genetic abnormalities whereas CFH mutations were detected in less than 10% of the genetically studied population. These initial results may confirm the racial differences between Turks and other populations. One of the limitations of our study was that we did not screen for thrombomodulin mutations, which have a minor role in aHUS [Although we have limited data on genetics, the results of our study might provide a general idea of the underlying genetic abnormalities in Turkish patients with aHUS. It has recently been reported that 60–70% of patients with aHUS carry identifiable mutations in complement genes or anti-CFH antibodies, which result in TMA lesions . In a mumalities , 18. In  in aHUS .Before the introduction of eculizumab, plasma therapy was the mainstay of treatment for aHUS, based on the premise that it was beneficial by supplying normal complement proteins and/or removing mutant proteins or autoantibodies , 12. AftMCP mutations were the most common; the mean duration of eculizumab treatment was 5.5 months, and hematological remission occurred in 82% of the patients. The authors reported that the mean improvement in eGFR from baseline to week 27 was 64 mL/min/1.73 m2, and discontinuation of dialysis was possible in 82% of the patients who initially required renal replacement therapy [The introduction of eculizumab has profoundly changed the management of aHUS. The efficacy of eculizumab has been demonstrated in three prospective clinical trials performed primarily in adult patients with TMA , 20, 21. therapy . In our  therapy . Later,  therapy . In our 2 during the follow-up period. Our results suggest that aHUS is a treatable disease and that progression to ESKD can be prevented with early diagnosis, and meticulous treatment and follow-up. However, it should be noted that in our patient cohort, high frequency of MCP mutations, lack of information on completed genetic data and early initiation of treatment may explain favorable outcome.Another noteworthy feature of our study is that we completed almost 2 years of patient follow-up. It has been previously reported that the mortality rate in children with aHUS was higher than that in adults, but the renal outcomes were worse in adults than in children [We have established a unique Turkish aHUS registry that will increase our knowledge of patients with aHUS who have different genetic backgrounds, and enable the evaluation of different treatment options and patient outcomes. This registry is now open to adult patients. The collection of data on adult patients with aHUS will help researchers to better characterize the spectrum of adult aHUS in the country and will enable comparisons with pediatric cases.


In assisted reproductive technology, it is important to choose high quality embryos for embryo transfer. The aim of the present study was to determine the grade Aembryo count and factors related to it in infertile women. This historical cohort study included 996 infertile women. Themain outcome was the number of grade A embryos. Zero-Inflated Poisson (ZIP) regression and Zero-Inflated Negative Binomial (ZINB) regression were used to model the countdata as it contained excessive zeros. Stata software, version 13  was used for all statistical analyses. After adjusting for potential confounders, results from the ZINB model show thatfor each unit increase in the number 2 pronuclear (2PN) zygotes, we get an increase of1.45 times as incidence rate ratio : 1.23-1.69, P=0.001) in theexpected grade A embryo count number, and for each increase in the cleavage day we geta decrease 0.35 times  in expected grade A embryo count.There is a significant association between both the number of 2PN zygotesand cleavage day with the number of grade A embryos in both ZINB and ZIP regressionmodels. The estimated coefficients are more plausible than values found in earlier studiesusing less relevant models. On the basis of The International Committee for Monitoring Assisted Reproductive Technology and the World Health Organization (WHO), infertility is defined as failure to achieve a clinical pregnancy with having regular unprotected intercourse for 12 or more months ,4. in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatments (Assisted reproductive technology (ART) is a collection of medical steps for the treatment of infertility. From 1978 (when the first ART baby was born) to 2012, ART has contributed to the birth of more than 5 million infants worldwide (eatments . In rece2), human chorionic gonadotropin(hCG) injection day, cleavage day , stimulation day, duration of fertility prevention, sperm quality, oocyte quality, duration of infertility, and number of metaphase I and metaphase II oocytes, germinal vesicles (GV), 1 pronucleus (1PN) zygotes, 2PN zygotes, injected oocytes, in vitro fertilized oocytes, ampoules and previous ART treatments. This historical cohort study consisted of 996 infertile women who presented at the Royan Institute, Tehran, Iran, between January 2012 and December 2013 with primary or secondary infertility. Infertile couples with a grade A embryo count record were included in the study. Couples who did not give consent and cases whose grade A embryo count was missing were excluded from the study. The main independent outcome was the number of grade A (or grade one) embryos. A grade A embryo is the one in which all the blastomeres are the same size and there is no fragmentation within the embryo. Potential confounding factors considered in the analysis were mother’s age in years, body mass index . Informed consent was obtained from all participants and they were assured that the results would be published as statistics with no possibility of identifying any personal data. The number of grade A embryos is a count variable. Poisson regression is used to model count variables. Zero-Inflated Poisson (ZIP) regression was used to model this count data as it contained excessive zeros. In this study, the outcome variable of interest was the number of grade A embryos, which was zero in 87.18% of cases. The Vuong test was used to confirm the choice of the ZIP model over ordinary Poisson regression. In the Vuong test, a significant z-test indicates that the ZIP model is better than an ordinary Poisson regression model. Also a test for over-dispersion was done using the likelihood ratio test and based on its results; Zero-Inflated Negative Binomial (ZINB) regression and ZIP model was done. Stata software, version 13  was used for all statistical analyses. Out of 996 infertile women who were referred to the Royan Institute in Iran for ART, the number of grade A embryos in 857 cases (87.18%) was zero and the mean (SD) number of grade A embryos was 0.27 (0.86), range 0-7 . 2. Other baseline characteristics of theparticipants are presented in Table 1. The Vuongtest showed that there is a significant differencebetween a ZIP model and an ordinary Poissonregression model , whichindicates that a ZIP regression model is a better fitfor this data. On the bases of the crude analysis,cleavage day (P<0.001), 2PN number (P<0.001),number of injected oocyte (P<0.001) and metaphase II number (P<0.001) have a significantrelationship with the number of grade A embryos.Previous number of ART treatments (P=0.068)and mother’s age (0.068) approach significance atthe P<0.05 level.As shown in Table 1, the mean age of themothers was 35.49 years old and mean BMI was25.56 kg/m2) 25.56 3.88 25.32-25.81hCG injection day 12.36 2.55 12.20-12.52Cleavage day 1.51 0.70 1.46-1.55Stimulation day 9.70 1.68 9.57-9.841PN number 0.22 0.57 0.19-0.262PN number 4.33 3.17 4.13-4.53Number of injected oocyte 7.42 4.15 7.15-7.68Metaphase I number 0.47 1.12 0.40-0.54Metaphase II number 7.11 4.22 6.85-7.38GV number 0.48 1.20 0.40-0.55Ampoule number 29.20 13.04 28.38-30.02Previous ART number 1.36 0.48 1.33-1.39Duration of fertility prevention in year 6.96 5.20 6.63-7.29Duration of infertility in year 0.89 1.83 0.78-1.01CI; Confidence interval, BMI; Body mass index, hCG; Human chorionic gonadotropin, PN; Pronucleus zygotes, GV; Germinal vesicles, andART; Assisted reproductive technology.in the model and displayed in Table 2 have nosignificant relationships with the number of gradeA embryos.In a ZIP regression model which included thepotential confounder variables, 2PN numberand cleavage day show a significant relationshipwith the number of grade A embryos, while theassociation of stimulation day and 1PN numberwith the number of grade A embryos approachedsignificance. For each increase of 2PN numberthe expected grade A embryo count increased by1.32  and for eachincrease in the cleavage day the expected grade Aembryo count decreased by 0.60 . Other variables that were includedTable 1: The baseline characteristics of participants in the studyVariable Mean SD 95% CI for meanAge of mother (Y) 35.49 5.33 35.16-35.82BMI  and sowas performed. The results of ZINB model showedthat after adjusting for the potential confoundervariables, each unit increase in the cleavage daydecreased the expected grade A embryo count by0.35 , and for eachunit increase in the 2PN number the expected gradeA embryo count increased by 1.45 . Comparison of the two models (e.g.ZIP and ZINB) with Akaike’s information criterion(AIC) indicates that the ZINB model has the smallerAIC (613.5 for ZINB and 626.7 for ZIP).Despite the remarkable advances in ourunderstanding of embryo development,identifying embryos with higher chance ofsurvival and development is still challenging.Prior studies have noted that good morphologygrade embryos are important in ART due totheir association with significant improvementof implantation and live birth rates . ThisstThe results obtained from the likelihoodratio test showed that the estimated mean andvariance are substantially different; thereforea ZINB regression model is preferred to a ZIPmodel. Although both the ZIP and ZINB modelfitted the data well, and the same variableswere selected by both models, the AIC showedthat ZINB is a better model to determine thefactors associated with the number of gradeA embryos, since a model with a lower AICis more plausible than one with a higher AIC. The estStrong evidence of a relationship betweencleavage day and number of grade A embryos wasdetected in the crude analysis, but it was not dueto confounding by other variables since earliercleavage was still associated with a greater numberof grade A embryos after being adjusted for othervariables in ZINB model as well as the ZIP model.This finding is in compliance with previous studieswhich identified the role of cleavage stage as akey role for successful ART cycles -14. It cAnother important finding in the adjustedanalysis, revealed by both the ZINB and ZIPmodels was the positive association between thenumber of embryos originated from 2PN zygotesand the number of grade A embryos. This finding isconsistent with those of previous studies showingthat 2PN zygotes tend to cleave to embryos withsufficient morphological quality , 17, 18.Age was marginally significant in the crudeanalysis, but it was not significantly associatedwith the number of grade A embryos after adjustingfor other confounding variables in either the ZINBor the ZIP multivariate models. Although thisresult differs from the results of some publishedstudies , 22, it The number of 2PN zygotes and cleavage day have a significant relationship with the number of grade A embryos in both ZINB and ZIP regression models.


The electrocardiogram (ECG) is the most commonly used tool to screen for left ventricular hypertrophy (LVH), and yet current diagnostic criteria are insensitive in modern increasingly overweight society. We propose a simple adjustment to improve diagnostic accuracy in different body weights and improve the sensitivity of this universally available technique.2) initially underwent cardiac magnetic resonance evaluation of anatomical left ventricular (LV) axis, LV mass and 12-lead surface ECG in order to generate an adjustment factor applied to the Sokolow–Lyon criteria. This factor was then validated in a second cohort .Overall, 1295 participants were included—821 with a wide range of body mass index  approaching that seen in normal weight (37.8%). Similar results were achieved in the validation cohort  again approaching normal weight (39.0%). Importantly, specificity remained excellent (>93.1%).Adjusting the Sokolow–Lyon index for BMI  improves the diagnostic accuracy for detecting LVH. As the ECG, worldwide, remains the most widely used screening tool for LVH, implementing these findings should translate into significant clinical benefit. As electrocardiographic determination of left ventricular hypertrophy (LVH) is not costly, is simple to perform and yields indices linked to mortality,2 in 1949)12The two most commonly used ECG criteria are the Sokolow–Lyon indexAlthough previous attempts have been made at improving the diagnostic accuracy of the ECG by adjusting for body habitus, they have either relied on echocardiographic determination of LV mass,The aim of this study was to develop a simple BMI-based adjustment factor for the ECG that could be used in everyday clinical practice to improve diagnostic accuracy of the detection of LVH in the modern population, where obesity is increasingly prevalent.2). The group was predominantly Caucasian in origin.All research data acquisition was approved by the local research ethics committee and informed written consent was obtained from each participant. Participants were recruited from the Oxfordshire population to studies within the Oxford Centre for Clinical Magnetic Resonance Research (OCMR) between 2005 and 2012. A flow chart of subjects through phase I of the study is shown in 2).All 520 adult participants for the validation cohort were recruited in the same fashion, with additional recruitment from the Division of Cardiology, Department of Medicine Research, University of Capetown, South Africa. To maximise generalisability of the study, within this cohort, 9.3% were African  and 90.7% were Caucasian. Inclusion and exclusion criteria were as described above. A retrospective analysis was performed on these 520 adult participants , overweight (25.0–29.9 kg/m2) or obese (>30.0 kg/m2). Blood pressure was recorded   and used to calculate BMI. Subjects were grouped according to World Health Organisation BMI categories: normal (18.5–24.9 kg/mn Corp.) .The anatomical axis of the LV was determined in the coronal and sagittal planes using multiplanar reconstruction of transverse thoracic HASTE images within cmr42 . The anatomical LV axis was defined as the plane between the centre of the mitral valve and the LV apex determined on both the horizontal and vertical long axis views. The LV axis in both planes  was determined using a commercially available screen protractor . Representative images of this process are shown in All imaging was ECG gated and acquired during breath-hold. In brief, a short axis stack of LV images was acquired  using a steady-state free precession sequence  as previously described.201+R-wave lead V5 or V6)3).A standard 12-lead ECG was performed in all participants  on the same day as the CMR. ECG measurements were performed manually by two experienced readers with >10 years of experience in ECG interpretation (OJR & DH). The analysis was blinded to participant's BMI and LV mass. The following ECG criteria were examined as reference standards: Sokolow–Lyon voltage (S-wave V2 and McNemar testing were performed. Data are presented as receiver operating characteristic (ROC) curves and overall diagnostic accuracy was interrogated using the Youden index. The values of p<0.05 were considered as statistically significant.All statistics were analysed using commercial software . All data were normally distributed according to Kolmogorov-Smirnov testing and the results are presented as mean (SD). Group comparison data were analysed using ANOVA with Bonferroni correction. Analysis of the effects of BMI and LV axis on ECG criteria was performed using Analysis of Covariance (ANCOVA) with post hoc Bonferroni correction. Homogeneity of variance was tested with Levene's tests and visually with residual plots. Sensitivity and values were calculated before and after correction for BMI and presented with 95% confidence intervals (CIs). Positive and negative predictive values and diagnostic accuracy are also calculated. To compare the diagnostic accuracy improvements, χOf the 821 participants, 172 had CMR-defined LVH (21.0%). Despite an increase in LV mass with obesity , Sokolow–Lyon index voltage criteria decreased by 4 mm (p<0.001) and Cornell criteria did not increase p>0.99, . This suThe Sokolow–Lyon criteria had poor sensitivity of 14.7% (CI 10.0% to 20.8%) but excellent specificity of 96.7% (95.1% to 97.8%) for the detection of CMR-determined LVH. Overall, diagnostic accuracy was very poor; ROC area under curve (AUC) was 0.55, Youden index was 0.11 (CI 0.05 to 0.16), positive predictive value was 0.52 (CI 0.37 to 0.67) and negative predictive value was 0.81 (CI 0.78 to 0.83) .2 12.6, p=0.02). In contrast, the specificity was seen to increase with increasing obesity , overweight 98.2% (95.5% to 99.3%) and obesity 99.0% (96.4% to 99.9%), However, this diagnostic performance was also too dependent on body habitus. The diagnostic sensitivity of the Sokolow–Lyon index is reduced with increasing BMI , overweight 12.8% (CI 6.9% to 22.7%) and obesity 3.1% (CI 0.4% to 10.8%), χThe Cornell criteria had comparable diagnostic performance with the Sokolow–Lyon criteria with 14.8% (10.4% to 20.1%) sensitivity and 96.7% (94.9% to 97.8%) specificity for detecting LVH. Again, a fall in sensitivity was seen with obesity from 21.1% (11.1% to 36.4%) to 11.9% (6.2% to 21.8%) with no change in specificity .When considering the whole study cohort, the incidence of a more leftward anatomical axis  increased from 13% in normal weight to 58% in the obesity, with leftward displacement of the LV axis in the coronal plane and superior displacement in the sagittal plane by on average 17° (both p<0.001).2 ) with reducing Sokolow–Lyon voltage with increasing lateral axis displacement . There were no significant changes in Cornell criteria .In order to determine the effect of an increasing leftward anatomical axis on ECG voltage criteria, subjects were matched for both LV mass and BMI. This showed that, for a given LV mass and BMI, a leftward deviation of the LV anatomical axis was associated with a significant decrease in Sokolow–Lyon amplitude . Similar results were seen using ANCOVA analysis investigating the effects of LV axis deviation on ECG criteria . Similar results were seen using ANCOVA analysis investigating the effects of obesity on ECG criteria ) with reducing Sokolow–Lyon index with increasing BMI .The adjustment factors for the overweight and obese cohorts were calculated as the maximum sum of the effects of both BMI and leftward anatomical LV axis deviation. This showed that when matched for LV mass, on average, a 4 mm reduction in ECG voltage amplitude was observed in overweight and an 8 mm reduction was observed with obesity. As no significant change in Cornell criteria was observed with increasing BMI, no adjustment factor was calculated.When adjusting the Sokolow–Lyon index  for the entire initial study group, the sensitivity increased from 14.7% (10.0% to 20.8%) to 31.4% (24.9% to 38.7%) p<0.001, . The larIn order to validate the proposed ECG adjustment, this was repeated in an independent cohort of 520 participants. Of these, 48 had CMR-defined LVH (9.3%). As with the initial cohort, despite an increase in LV mass accompanying obesity , ECG voltage criteria decreased by 4 mm p<0.001, .When adjusting the Sokolow–Lyon index  for the entire validation cohort, sensitivity increased significantly from 17·9 (8·9–28·7) to 28·1 (17·6–40·8), p<0.001, Although the Sokolow–Lyon and Cornell criteria are frequently used in clinical practice and appear widely in international guidelines, in the modern era of increasing obesity, their diagnostic accuracy is well below an acceptable level for a diagnostic screening tool. This study has shown that by incorporating BMI into the ECG algorithm by a simple adjustment, the diagnostic sensitivity can be improved without a significant decrease in specificity.In current practice, LVH is most accurately determined by CMR, as its accuracy far exceeds that of either echocardiography or ECG.It has previously been shown that the diagnostic sensitivity of the ECG can be improved by accounting for obesity. However, prior studies have either used 2D echocardiography to determine LV mass, which itself is limited in obesityGiven the global utilisation of this criteria as well as the worldwide increase in obesity, this finding is of significant clinical impact and should allow a substantial increase in the detection of anatomical LVH using ECG screening. As ECG-determined LVH appears in both European and US guidelinesECG criteria for LVH severely underestimate the prevalence of anatomical LVH, especially in the setting of obesity. We propose a simple adjustment of the ECG Sokolow–Lyon criteria  that improves the diagnostic sensitivity for the detection of anatomical LVH without significantly decreasing the diagnostic specificity.The electrocardiogram (ECG) remains the most widely used clinical screening tool for the detection of left ventricular hypertrophy (LVH), and yet existing diagnostic criteria are increasingly insensitive due to their inaccuracy in higher body weights.2) and by +8 mm in patients with obesity (BMI >30 kg/m2) improves the diagnostic accuracy for detecting LVH.Adjusting the Sokolow–Lyon index by +4 mm in patients with overweight (body mass index (BMI) is 25–30 kg/mThis simple, clinically usable adjustment criterion significantly improves the power of the 12-lead ECG to detect LVH. Improving the diagnostic accuracy of the ECG should increase the number of patients identified with asymptomatic end organ damage in at-risk populations, improve risk stratification and may reduce the need for further unnecessary investigation.