The presence of shunt was associated with lower 6MWD, lower blood saturation at rest, and higher desaturation after effort. Patients in III/IV WHO-FC achieved higher rest HR and maximal HR in comparison to patients in I/II WHO-FC (63.1 vs. 55.2% p < 0.01) and lower 6MWD (64.3 vs. 77.5% p < 0.01). In 14 out of 20 6MWT performed after treatment intensification, increase of distance was observed. The results of 6MWT were consistent with clinical status  but not with echocardiography parameters. 6MWT may be the source of additional information in management of children with PAH.Six-minute walk test (6MWT) is a submaximal exercise test applied for evaluation of adults with pulmonary arterial hypertension (PAH). It was widely used as an endpoint in the clinical trials. The aim of the study was to assess the usefulness of 6MWT in management of children with PAH and to establish correlations with other clinical features. 164 6MWT were performed in 15 children between 5 and 18 years with PAH confirmed by right heart catheterization . Distance in 6MWT (6MWD)—% of predicted for age and gender, desaturation at the maximum effort, peak heart rate (HR)—% of maximal HR, were compared to the level of NTproBNP, WHO-FC, echocardiography parameters, and events of PAH treatment intensification. 6MWD had low negative correlation with peak HR ( It was The aim of this study was to assess the usefulness of 6MWT for evaluation of children with pulmonary arterial hypertension and to establish correlations with other clinical features.ostium secundum, partial anomalous pulmonary venous drainage, tricuspid atresia, atrio-ventricular septal defect, idiopathic PAH after Potts shunt, and 62 in children without shunt—idiopathic PAH, postoperative congenital heart defect . The age during the test was 5–18 years , and there were no patients with Down syndrome and physical or mental disability. Distribution of tests performed in patients in I/II WHO functional class (WHO-FC) and III/IV WHO-FC was 129 to 35. 102 tests were done in patients with shunt—multiple ventricular septal defects, atrial septal defect  Procedures analyzed in this study are the part of standard care of patients with pulmonary hypertension. All are required by the National Health Fund to reimbursement of pharmacotherapy. Informed consent to participate in the therapeutic program of the National Health Fund was obtained in all patients.p < 0.05. Obtained data were shown on the boxplot. Differences among three groups of tests  were analyzed using analysis of variance (ANOVA). To measure the association between two measured quantities, Kendall’s rank correlation coefficient (tau) was used.Continuous data were presented as values with an average, a standard deviation, and a median. Normal distribution was determined using Shapiro–Wilk test. To compare of distribution in groups, parametric (T-student) and non-parametric (Whitney–Mann) tests were used. The limit for statistical significance was set at  In all tests, reached distance adjusted to age and gender ranged from 22 to 109% of predicted value . 11 patients in 51 tests reached distance more than 80% predicted (good result group). In this group, a lower WHO-FC (92% WHO-FC I/II) and a lower level of NTproBNP (431.1 ± 762.2) were found. 55% of tests were performed by patients with PAH without shunt therefore with higher saturation, and lower mean desaturation. 7 patients in 20 tests did not achieve 60% PPD (poor result group). Mean age during tests was lower than in other groups. 75% tests in this group were performed by patients with shunt therefore the rest saturation was lower. Patients were in higher WHO-FC (80% WHO-FC III/IV), with higher level of NTproBNP (3108.5 ± 2495.4), rest HR, and peak HR despite the increase heart rate (ΔHR) was lower. There were no differences in echocardiography parameters irrespectively of 6MWT results .τ −0.1 p = 0.03)   Fig.  and nega Fig.  an02) Fig. .20 events of treatment intensification were detected in 11 patients    . Walk distance in patients with shunt was lower than without shunt (73 vs. 77% 02) Fig. . No diff01) Fig. .p < 0.01)    . Patients in III/IV WHO-FC achieved significantly lower walk distance than children with I/II WHO-FC (64.3 vs. 77.5% 01) Fig. , similar01) Fig. . Only in01) Fig. .This study demonstrated that the results of 6MWT in children with pulmonary hypertension are associated with clinical status, especially with WHO-FC and NTproBNP which are unquestioned prognostic factors in this disease . No depeThe usefulness of the 6MWT was confirmed in many studies in adults –12, so iMany authors evaluated the results of 6MWT in children with chronic diseases , but not echocardiography parameters. 6MWT may be the source of additional information in assessment and management of children with PAH. 6MWT repeated in routine control may be helpful in treatment decisions.


Therapeutic drug monitoring (TDM) aid therapeutic decision making in patients with inflammatory bowel disease (IBD) who lose response to anti-TNF therapy. Our aim was to evaluate the frequency and predictive factors of loss of response (LOR) to adalimumab using TDM in IBD patients.One hundred twelve IBD patients  were enrolled in this consecutive cohort from two referral centres in Hungary. Demographic data were comprehensively collected and harmonized monitoring strategy was applied. Previous and current therapy, laboratory data and clinical activity were recorded at the time of TDM. Patients were evaluated either at the time of suspected LOR or during follow-up. TDM measurements were determined by commercial ELISA .p < 0.001, OR:7.8 CI 95%: 2.5–24.3, ADA positivity: p = 0.007 OR:3.6 CI 95%: 1.4–9.5).Among 112 IBD patients, LOR/drug persistence was 25.9%/74.1%. The cumulative ADA positivity (>10 ng/mL) and low TL (<5.0 μg/mL) was 12.1% and 17.8% after 1 year and 17.3% and 29.5% after 2 years of adalimumab therapy. Dose intensification was needed in 29.5% of the patients. Female gender and ADA positivity were associated with LOR  contains supplementary material, which is available to authorized users. Inflammatory bowel diseases (IBD) are chronic conditions that significantly influence quality of life (QoL) and can lead to disability and complications. Anti-tumor necrosis factor alfa (anti-TNF) therapy is effective in IBD, demonstrating improvement in patients’ QoL, leading to clinical remission and mucosal healing, reducing the need for surgery and hospitalizations. However, approximately 10-30% of the patients do not respond to the initial treatment and app. one third of the patients lose response to anti-TNF therapy over time . TherapeHowever, less data is available on the relevance of TDM assessment during adalimumab therapy, whether TLs and ADA levels are strongly associated with disease outcome remains questionable. Although correlation between the adalimumab drug concentration and clinical outcome was reported, the role of routine TDM assessment during adalimumab therapy remained unclear . In the The aim of the present study was to evaluate the frequency and predictive factors of loss of response to adalimumab therapy and the role of TDM to predict LOR in adalimumab treated IBD patients.Patients were consecutively enrolled in this cohort between 2014 November and 2016 June from two referral IBD centres in Hungary. Demographic data were comprehensively collected and a harmonized monitoring strategy  was applied as requested by the Hungarian National Health Fund . PreviouPatients were evaluated either at the time of suspected LOR  or during regular follow-up visits with TDM measurement using a conventional and bridging enzyme-linked immunosorbent (ELISA) assay . For the measurement of ADA levels, the bridging ELISA method uses a double-antigen bridge: ADAs create a bridge between adalimumab immobilized on the plate and adalimumab enzyme-linked conjugate. ELISA measurements were performed at the Department of Laboratory Medicine, Semmelweis University, Budapest. All ELISA kit was validated for accuracy and reproducibility of TDM for adalimumab . The limit of detection for the adalimumab drug level is 0.1 μg/mL determined by the manufacturer of the assay. The optimal therapeutic cut-off value for low adalimumab TL was defined as 5 μg/ml, in concordance with previous studies. The standard cut-off value of detectable ADA levels by the assay was 10 ng/ml. To better stratify ADA positive patients we defined ADA levels more than 200 ng/ml as ‘high’ ADA level. Transient ADA was defined when the ADA positivity disappeared on the next TDM of the patient. In CD, clinical remission was defined as Crohn’s Disease Activity Index (CDAI) < 150 points or no fistula drainage as assessed by the Fistula Drainage Assessment, while clinical response was defined as a decrease in CDAI with more than 70 points or at least 50% reduction in the number and production of draining fistulas . In patip < 0.2 in univariate analysis were included in the multivariate models). For time-dependent outcomes Kaplan-Meier curves were plotted was performed. A p-value of <0.05 was regarded as statistically significant. Statistical analysis was performed using the SPSS software v. 20.0 .For categorical data frequency distributions were analysed, for continuous variables mean and SD were calculated. Chi-squared test was used to evaluate differences within subgroups of patients and binary logistic regression was performed for multivariate analysis .One hundred twelve IBD patients  (SD: 10.9/11.2 y) were enrolled in this consecutive cohort. Detailed patient characteristics are shown in Table The frequency of previous and current 5-aminosalicylate (5-ASA), steroid and azathioprine (AZA) exposure were 85.6%/26.8%, 92.9%/6.3% and 77.7%/44.7%. Previous anti-TNF therapy was present in 65.2%  in the IBD cohort. Mean duration of adalimumab therapy during follow-up was 157.8/70.1 weeks (SD: 101.7/58.0 weeks) in CD/UC.p = 0.156). The combination of normal TL and no ADA, normal TL and ADA positivity, low TL and no ADA, and low TL and ADA positivity were observed in 58%, 10.7%, 21.4% and 9.8% at TDM measurement . Among the ADA positive patients, 7 patients had high ADA titres (>200 ng/ml) and 7 patients had only transient ADA positivity (6.3%). Frequency of low TL (<5.0 μg/mL) was 31.3% (35/112). Cumulative ADA positivity was 12.1% and low TL rate was 17.8% after 1 year, and 17.3% and 29.5%, respectively after 2 years of adalimumab therapy. Concomitant immunomodulatory (IM) therapy was not associated with ADA positivity (Dose intensification was needed in 29.5% of patients and 25.9% of the patients had loss of response during the follow-up. The rate of LOR was similar in the two different IBD centres (25.4% and 26.5%). In Kaplan-Meier analysis, probability of dose intensification and LOR was 19.7% and 17.5% in the first year and 30% and 18.8% in the second year of adalimumab therapy , furthermore this difference was significant when analysing patients with low and high ADA titre separately. Rate of low TL in patients with high ADA was 85.7%, while it was 28.6% in patients with low ADA and 27.5% in ADA negative patients (p = 0.006). There was no association between TL and LOR.Though the association between low TL and ADA positivity was statistically not significant, the trend towards an association is clear , even if patients with low or high titre ADA  were analysed separately. The association was significant in CD with a similar trend in UC patients .ADA positivity was significantly associated with LOR .Transient ADA was marginally associated with LOR , especially in CD  with the same trend in UC.LOR was more frequent among patients with dose intensification  both in CD and UC. In a sensitivity analysis, results remained similar if the data from the two centres were analysed separately. In contrast, there was no association between female gender and dose intensification, low TL or ADA positivity.There was a significant association between LOR and female gender  and ADA positivity  remained independent predictors of LOR in a multivariate analysis.Gender .Finally, dose intensification was associated with need of steroid therapy in patients with CD  had low TL in 85%. Despite of ADA development, low TL was not associated with LOR. This suggests that primarily ADA positivity should be considered as an indicator for treatment failure. Similarly, Roblin et al. suggested that low TL without ADA can be overcome by dose optimization with a high rate of clinical response (67%) after dose optimization and is not leading per se to LOR. In contrast, low TL with detectable ADA is associated with treatment failure, and switching to another anti-TNF or other therapeutic class should be considered . AdditioMore than half of our patients received another anti-TNF agent previously  in the present study. We did not find any association between previous anti-TNF therapy and LOR or ADA status, however the proportion of patients with previous anti-TNF exposure was very high (74/112). In contrast, in the study of Yarur et al., detectable ADA to adalimumab was associated with low adalimumab TL, previous infliximab use, macroscopic mucosal inflammation and need for corticosteroids . Similarp = 0.026) [Concomitant immunomodulatory (IM) therapy was not associated with ADA positivity, in line with previous studies , 13, 20.= 0.026) , 17.In the present study, there was an association between LOR and female gender both in CD and UC, even when data from the two referral centres were analysed separately. We did not find gender-related differences in other parameters . In a previous retrospective study by Cohen et al. , gender Low adalimumab TL was defined as <5 μg/mL, in concordance with previous studies. However, reported cut-off values vary. Mazor et al. identified a drug TL of 5.85 μg/mL as the optimal cut-off for predicting remission  in CD . In a JaCurrent tests for anti-TNF and ADA concentrations are mostly based on enzyme immunoassays. For existing commercially available assays for antibodies, the presence of drug generally interferes with the detection of ADAs. All ADA assays are drug-sensitive to some extent because most assays use the drug itself as labeled detecting antibody. Newer assays, based on high-performance liquid chromatography or the pH shift-anti-idiotype method, which can detect ADAs in the presence of circulating drug have been developed, however most of these methods only available for infliximab and also not accessible in everyday clinical practice , 25.The strengths of the present study are the harmonized monitoring strategy, prospective collection of clinical and laboratory data. Limitations of the study include the relatively small cohort size, especially in UC. Multiple TDM samples were available only in few patients. Of note, unlike infliximab, there are very few studies evaluating serial TDM measurements in adalimumab therapy. Further investigation is needed applying serial/routine TDM measurements to determine the exact role and usability of routine TDM in adalimumab therapy. In addition, whether TDM for adalimumab needs to be performed at trough remains conflictive in current literature and definitely requires more research. Of note, in a very recent paper by Ward et al. author have shown only little variation in drug levels during maintenance adalimumab therapy assessed on days 4-6, 7-9 and 13-14 (trough level). Importantly, drug levels on day 9 were the best predictor of a therapeutic drug trough level .The present study suggests that ADA development, low TL and need for dose intensification are frequent during adalimumab therapy and our results support the use of selective TDM assessment in IBD patients on adalimumab therapy. ADA positivity was identified as predictor of loss of response.


The objectives of this study were to evaluate the prevalence and infection intensity of intestinal parasites in different dog and cat populations in Crete, Greece, estimate the zoonotic risk and identify risk factors.Giardia and Cryptosporidium were detected by a quantitative direct immunofluorescence assay (IFA). PCR and sequencing was performed to evaluate the zoonotic potential of Giardia and Cryptosporidium positive samples.Faecal samples from shelter, household and shepherd dogs and shelter and household cats were analyzed using sedimentation/flotation techniques. Giardia spp.; 9.2% (CI: 7.3–11.1) for Ancylostoma/Uncinaria spp.; 7.6% (CI: 5.9–9.4) for Toxocara spp.; 5.9% (CI: 4.4–7.5) for Cryptosporidium spp.; 4.6% (CI: 3.2–5.9) for Cystoisospora spp.; 2.7% (CI: 1.7–3.8) for Toxascaris leonina; 1.7% (CI: 0.9–2.6) for Capillaria spp.; 0.8% (CI: 0.2–1.4) for taeniid eggs; 0.2% (CI: 0–0.5) for Dipylidium caninum; and 0.1% (CI: 0–0.3) for Strongyloides stercoralis. In cats, the prevalence was 20.5% (CI: 15.6–25.3) for Giardia spp.; 9.5% (CI: 5.9–13.0) for Cystoisospora spp.; 8.3% (CI: 5.0–11.7) for Toxocara spp.; 7.6% (CI: 4.4–10.8) for Ancylostoma/Uncinaria spp.; 6.8% (CI: 3.8–9.9) for Cryptosporidium spp.; 4.2% (CI: 1.8–6.6) for Capillaria spp.; 0.8% (CI: 0–1.8) for taeniid eggs; and 0.4% (CI: 0–1.1) for Hammondia/Toxoplasma. Concerning the risk factors evaluated, there was a negative association between age and Giardia infection and between age and T. leonina infection intensity for dogs. Sequencing results revealed the presence of mainly animal-specific G. duodenalis assemblages C and D in dogs and assemblages F, C and BIV-like in cats, with only a limited number of (co-)infections with assemblage A. As for Cryptosporidium, the dog-specific C. canis and the pig-specific C. scrofarum were detected in dogs and the cat-specific C. felis was detected in cats.Totals of 879 dog and 264 cat faecal samples were examined. In dogs, the overall prevalence was 25.2% (CI: 22.4–28.1) for Giardia was the most prevalent parasite in all dog and cat populations except for shepherd dogs. Genotyping results suggest a limited zoonotic risk of Giardia and Cryptosporidium infections from dogs and cats in Crete. Taeniid eggs were more prevalent in shepherd dogs suggesting access to carcasses and posing a threat for cystic echinococcosis transmission. Infection rates of Toxocara spp. in both dogs and cats show that companion animals could be a significant source of infection to humans.High levels of parasitism in both dogs and cats were recorded. The online version of this article (doi:10.1186/s13071-017-1989-8) contains supplementary material, which is available to authorized users. Giardia spp., Cryptosporidium spp., Toxocara spp., hookworms and Echinococcus granulosus  which is also confirmed by the multivariate zero-inflated model, according which the odds of absence of Giardia cysts are increased by one unit increase of age. Similarly, according to the multivariate zero-inflated model, as age increased by one month, the odds of detecting T. leonina eggs decreases by 7% = [(0.93–1) × 100]. Regarding the other parasites studied, their correlation with age was not statistically significant.The mean age of the sampled dogs was approximately 3 years . The majority of the dogs were adults . Moreover, there was a statistically significant association between the factors “recent record of diarrhoea” and “live with other animals”, (χ2N = 1138).Of the dogs which had a history of recent diarrhoea, 43.1% were positive for at least one intestinal parasite. However, faecal consistency was not significantly associated with parasitic infection. The statistical analyses showed that signs of diarrhoea (based on faeces consistency) were significantly more often present in younger animals . The arithmetic mean of anthelmintic treatments/year was 2.3 for household dogs, 2.2 for shelter dogs and 0.5 for shepherd dogs. Information about anthelmintic treatments was not defined in 48 cases (5.5%). The frequency of antiparasitic treatment was also associated with diarrhoea and more specifically, the effect of the odds of one treatment per year increase resulted in a decrease by 0.828 times in the trace of “recent record of diarrhoea”, implying diarrhoea to be caused by parasite infestation. However, the number of antiparasitic treatments/year received was not statistically associated with parasitic infection.The risk analyses of all the other factors which were evaluated in this study, such as the gender of the animals, their living conditions (indoors/outdoors), the type of food, and recent travelling, showed no statistically significant correlation with parasitic infection. Since almost all shelter dogs had access to the external environment and the shepherd dogs were also living outside, the risk factor “living indoors/outdoors” was assessed only for household dogs. The risk factor “recent travelling” was also not analysed since only 4.2% of the dogs had been travelling during the last months before sampling, including within counties. The same applied for the “type of food” factor, since the majority of the dogs were eating industrial/cooked food and only 28 were fed with raw meat/offal, 64% of these being shepherd dogs.Giardia spp. was the most prevalent parasite in all dogs (25.2%) and also in shelter (54.3%) and household (12.9%) dogs in particular. The range of the cysts being shed by the infected animals varied from 100 to 275,800 cysts per gram of faeces with 6,855 cysts shed on average. In the samples derived from shelter and household dogs, the dog-specific assemblages C and D were dominating, either alone (n = 72) or in mixed infections (n = 15). A limited number of dogs were infected with assemblage A (n = 2), assemblage AI (n = 1), assemblage AII (n = 1) or a mixture of A with C or D (n = 5) or BIV-like and C (n = 1)  for Cystoisospora spp.; 8.3% (CI: 5.0–11.7) for Toxocara spp.; 7.6% (CI: 4.4–10.8) for Ancylostoma/Uncinaria spp.; 6.8% (CI: 3.8–9.9) for Cryptosporidium spp.; 4.2% (CI: 1.8–6.6) for Capillaria spp.; 0.8% (CI: 0.0–1.8) for taeniid eggs; and 0.4% (CI: 0–1.1) for Hammondia/Toxoplasma. The results among different feline populations are shown in Table In total, 264 faecal samples from cats were collected; 59 samples from shelters and 205 from owned cats. Unfortunately, it was not possible to reach the target of 385 shelter cats. Overall, 38.1% of the cats were harbouring at least one intestinal parasite. Precisely 26.4% were harbouring one parasite, 8.3% two and the rest 3–4 different species. The prevalence was 20.5% (CI: 15.6–25.3) for n = 161), while 97 of them were younger than 12 months and 6 were of unspecified age.The mean age of the sampled cats was 3.4 years . The majority of the cats were adults , 32.9% were infected with at least one parasite. On average, all cats sampled received 2.3 anthelmintic treatments/year (range 0–6). The mean number of anthelmintic treatments/year was 1.9 for household cats and 2.7 for shelter cats. Information about anthelmintic treatments was unknown in one case. Only 1.5% of the cats had been travelling during the last months including within counties. No significant associations were found between parasite infections and risk factors or between parasite infections and diarrhoea.Giardia spp. was the most prevalent parasite (20.5%), both in shelter cats (39.0%) and household cats (15.6%). When targeting the 18S rRNA gene, assemblage A was identified in 10 cat samples. In 6 of these samples, no amplification was obtained with the other genes, while in 4 samples only assemblage F was detected in at least one of the other loci. Assemblage F was also found alone in 2 samples. Also, in two different cases, the typing revealed the presence of assemblage BIV-like (n = 1) or the dog specific assemblage C (n = 1) (Table Cryptosporidium positive samples showed the presence of the feline specific species Cryptosporidium felis (n = 4).Genotyping of Giardia spp. was the most prevalent parasite detected in the dog and cat populations followed by significant prevalences of ascarids, hookworms and taeniid infections. These results are also reported in other studies which consider Giardia the most common enteric parasite of dogs and cats in developed countries [The infection rates of intestinal parasites detected in this study, revealed a high prevalence of parasitic infections 38.2%) and the presence of different species of endoparasites in both dogs and cats. These infection rates were equally distributed within animal species (38.3% for dogs and 38.1% for cats) involved in the study. With the exception of shepherd dogs, % and theountries , 44–48. Among the targets of this study was to investigate the potential effect of animal lifestyle to parasitism so animals living in households, shelters or farms were included. The results showed that more than half of the shelter dogs and cats were infected with at least one species of endoparasite, which was more or less expected, taking into consideration the less hygienic conditions that those animal are living in combined with a high population density that usually exists in shelters. A high level of parasitism has been previously reported in shelter dogs , 22, 24 More than half of the shepherd dogs 51.4%) were positive for at least one species of intestinal parasite. The infection rate of intestinal parasites estimated in shepherd dogs in this study was higher than in a previous record from Greece (26.0%) . Such di.4% were Although the prevalence of intestinal parasites in household dogs was lower than in shelters, although not statistically significant for many species, the percentage of individuals infected was still noteworthy 23.8%). In similar studies conducted in Italy the prevalence of intestinal parasites in household dogs was even higher, reaching 57.0% of the animals , 23. In .8%. In swww.esccap.org). Recent modeling indicated that the environmental Toxocara contamination by dogs can only be reduced significantly if compliance to the four times a year treatment advice is sufficiently high (90%) or if at least half of the dog owners consistently remove their dog’s faeces [Although both household and shelter dogs received regular anthelmintic treatments (i.e. an average of 2.3 for household dogs and 2.2 for shelter dogs per year), this seemed not to control parasitism efficiently. This is in agreement with the general recommendation by ESCCAP for roundworms in which it is suggested that annual or twice yearly treatments do not have a significant impact on the prevalence of patent infections within a population, and therefore a treatment frequency of at least 4 times per year is recommended cyst output recorded in most cases cysts and clinical signs). It was not statistically proven that recent records of diarrhoea were correlated to parasitism as also shown previously , 55 althGiardia and Cryptosporidium positive samples were further investigated by PCR and sequencing of the positive PCR products. In dogs, the host-specific assemblages C and D dominated, which has been described before in various studies [G. duodenalis sample further revealed a multilocus genotype (MLG) which was previously described in calves in China [Giardia infections from dogs in Crete.Given the high prevalence and the potential zoonotic importance,  studies , 57–62.  studies , 64. Thein China . TogetheGiardia infections in cats.In cats, the genotyping results seemed to indicate the dominance of the potentially zoonotic assemblage A in shelter animals and the co-infection of assemblages A and the feline specific assemblage F in household cats. However, the zoonotic assemblage A was identified only at the 18S rDNA locus, while only assemblage F was identified at the other loci. Since no distinction could be made between assemblages A and F in the amplified region of the conserved rRNA 18S gene, it cannot be excluded that (some of) the samples that were amplified with rDNA 18S gene were assemblage F instead of A. Therefore, no conclusion can be drawn on the zoonotic risk associated with Cryptosporidium, the dog specific C. canis was identified in only two household dogs and the pig specific C. scrofarum in one shelter dog. Cryptosporidium canis has been also detected in household dogs in other studies [C. scrofarum infection reported in a dog. Since keeping backyard pigs is quite a common practice in the area, it is possible that this dog ingested the oocysts before being transferred to the shelter. In such a scenario this could be a case of pseudoparasitism, given that this dog was 2.5 month-old and only recently introduced to the shelter. In cats, sequencing was not efficient; nevertheless, it revealed the presence of the feline-specific C. felis. Since our genotyping results revealed the presence of host-specific Cryptosporidium species in both dogs and cats which have been implicated in very few human infections and mainly in developing countries, we could suggest that the zoonotic potential of Cryptosporidium from dogs in the study area is low.Regarding  studies , 65, 66  studies , 68, sugGiardia and Cryptosporidium, ascarids, hookworms and taeniids are also considered to be zoonotic [T. canis and T. cati (to a lesser extent) are responsible for human infections [Toxocara spp. in dogs and cats was 7.6 and 8.3%, respectively. In dogs, we characterised all Toxocara eggs found as Toxocara spp. since those infections were only microscopically diagnosed and as previously suggested they could either belong to T. canis or T. cati since coprophagy is not unusual for dogs and the presence of T. cati eggs in dog faeces might in fact relate to pseudoparasitism [T. canis in dogs from different epidemiological environments and from 7.2 to 76.0% for T. cati in cats [Toxocara infection was high, especially in shelter dogs and cats, as also reported before [T. canis is considered responsible for human toxocarosis [T. cati in human toxocarosis should not be underestimated [T. canis in children [Apart from zoonotic , 69–72. fections , 72. In rasitism , 74. The in cats , 75–79. d before , 80, 81.ocarosis , the rolstimated –84. In Gstimated , 86 and children . Our resHookworm infection rates were 9.2% in dogs and 7.6% in cats. The highest infection rates of hookworms were identified in shepherd dogs (33.3%) similar to the study of Mateus et al.  in PortuE. granulosus in livestock, which is transmitted through dogs, we could assume that shepherd dogs in Greece could be a reservoir for human infections.The detection of taeniid eggs in shepherd dogs is worth mentioning. Unlike shelter and household dogs, shepherd dogs seem to be more prone to taeniid infection, which possibly is due to the frequent consumption of raw meat and carcasses , 88. EchIn conclusion, we have recorded high levels of (multi)parasitism in both dogs and cats in the study area. Most of the animals were harbouring different species of parasites sometimes in high numbers according to the egg/(oo)cyst counts. This is a proof that those parasites are greatly abundant within animal populations regardless of lifestyle. Thus, the results of our study, stress the need for better anthelmintic control schemes in dogs and cats tailored to their individual needs in order to safeguard animal and public health.


Antiretroviral therapy (ART) has modified the natural history of HIV-infection: the incidence of opportunistic infections (OIs) has decreased and mortality associated to HIV has improved dramatically. The reasons for hospitalization have changed; OIs are no longer the most common reason for admission. This study describes the patient population, admission diagnosis and hospital course of HIV patients in Colombia in the ART era.Patients admitted with HIV/AIDS at six hospitals in Medellin, Colombia between August 1, 2014 and July 31, 2015 were included. Demographic, laboratory, and clinical data were prospectively collected.551 HIV-infected patients were admitted: 76.0% were male, the median age was 37 (30–49). A new diagnosis of HIV was made in 22.0% of patients during the index admission. 56.0% of patients of the entire cohort had been diagnosed with HIV for more than 1 year and 68.9% were diagnosed in an advanced stage of the disease. More than 50.0% of patients had CD4 counts less than 200 CD4 cells/μL and viral loads greater than 100,000 copies. The main reasons for hospital admissions were OIs, tuberculosis, esophageal candidiasis and Toxoplasma encephalitis. The median hospital stay was 14 days (IQR 8–23). Admission to the intensive care unit (ICU) was required in 10.3% of patients and 14.3% were readmitted to the hospital; mortality was 5.4%.Similar to other countries in the developing world, in Colombia, the leading cause of hospitalization among HIV-infected patients remain opportunistic infections. However, in-hospital mortality was low, similar to those described for high-income countries. Strategies to monitor and optimize the adherence and retention in HIV programs are fundamental to maximize the benefit of ART. Life expectancy for patients infected with the human immunodeficiency virus (HIV) has improved significantly in the era of antiretroviral therapy (ART), largely due to the reduction in mortality attributable to diseases related to acquired immunodeficiency syndrome (AIDS) . A recenAlthough the change in the epidemiological profile of hospitalized patients with HIV has been widely documented in high-income and in developing countries, little is known about the reasons for hospital admission and hospital outcomes in the current era of the HIV epidemic in Colombia , 12. Thi® software , and included socio-demographic variables, baseline characteristics at admission, reason for hospital admission and clinical outcomes. Patients that could not be interviewed were excluded from the analysis, but the reason for admission was recorded. The definitions of the variables were based on previous studies and those established by National Institutes of Health  27–149.5). Of the 430 patients with a previous HIV diagnosis, 42% (181 patients) had already had an opportunistic infection, with tuberculosis being the most common one. In this group, ART had been prescribed to 85.1% (366/430), but only 63.4% (273/430) were receiving it on admission, and only 199 patients (54.1%) reported being adherent to ART. The main reasons for non-adherence were drug dependence, social or occupational instability, psychiatric disorders and lack of family support. Multiple antiretroviral regimens have been received by 48% (175/366) of patients; the average number of previous regimens was 1.5 (SD ± 0.82).Baseline characteristics were similar for all patients compared to the subsets of patients with a previous HIV diagnosis and a prior AIDS-defining illness, except the median CD4 count was lower and the proportion of patients without antiretroviral therapy was greater in the AIDS-defining illness group Table .Table 1BThe main reason for hospitalization was an AIDS-defining illness in 54.6% (301/551) of patients, and tuberculosis was the most frequent OI in this group . The second most frequent reason for admission were non HIV-related affections with bacterial infections predominating  (Table Admission to the ICU was required in 57 patients (10.3%); of these, 33.3% (19) had tuberculosis. Median hospital stay was 14 days (IQR 8–23) and 14.3% (79) of patients required re-admission to the hospital. Adverse events to medications received during the hospital stay were reported for 9.6% (n = 57) of the patients. Nosocomial infections were reported for 27 patients (4.9%).Global mortality was 5.4% (30/551 patients). Of the patients who died, 70% (n = 21) had a previous diagnosis of HIV, 52.4% (n = 11) were receiving ART, and 38.1% (n = 8) were being followed-up in an HIV program. 96.6% (n = 28) of the patients that died had less than 50 CD4 cells/μL, 80% (n = 24) had been admitted for an AIDS-defining illness, and 36.6% (11 patients) had two or more OIs . Mortality is associated to advanced disease stages, severity of immunologic compromise (low CD4 count), presence of opportunistic infections, and lack of resources for care . AlthougStrengths of the study include that it is a large, multicenter study with prospective design. Patients that were not included were analyzed retrospectively, finding similar causes of admission to those reported for the entire cohort Fig. . Among tOpportunistic infections continue to be de the leading cause of hospitalization in adult HIV patients in Colombia. The gap between access to care and treatment and treatment goal achievement reflect possible programmatic limitations. Despite this, mortality rates observed were low, similar to those described for high-income countries. Our findings suggest focusing on measures to improve retention in care, ensure adherence and improve the opportunity for diagnosis, could have a long-term positive impact on the incidence of opportunistic infections and hospital admissions.


Left and right arteries were similar, except for the mediastinal trajectory in reference to the esophagus (p < 0.001) as well as the arterial diameter (p < 0.001) and lumen diameter. The aim of our study was to determine the prevalence of anatomical variants of bronchial arteries using computed tomographic angiography in a population of northeastern Mexico. An observational, transversal, descriptive, comparative, retrospective study was performed using 139 imaging studies of Mexican patients in which we evaluated the following parameters from the left and right bronchial arteries: artery origin, branching pattern, arterial ostium, vertebral level of origin, diameter, and mediastinal trajectory. The anatomies of the bronchial arteries were similar in both genders, except distribution for vertebral origin level ( Massive hemoptysis is a life-threatening clinical event . Its maiThe most effective nonsurgical treatment for massive hemoptysis is the embolization of bronchial arteries –13. Its The anatomical variants of the bronchial arteries have been reported in cadaveric studies, angiography, and computed tomography angiography (CTA); the latter was considered the most suitable method , 18–21. The objective of our study was to analyze the arterial origin, branching pattern, location ostium, vertebral level of origin, mediastinal trajectory, and diameter of the bronchial arteries using CTA.We performed a retrospective, observational, cross-sectional descriptive study, in which 297 angiograms were evaluated by CTA from a Mexican population, carried out in the Radiology and Imaging Division of the Hospital Universitario “Dr. José Eleuterio González.” Consecutive cases were selected between January 1, 2013, and December 31, 2015, from patients who were 18 years old or older, including those with suspected pulmonary, pleural, or heart pathologies. Studies from patients younger than 18 years were excluded. Pathologies that did not allow the proper evaluation of one or both bronchial arteries were eliminated (158 studies).CTA studies were performed using a 64-slice CT  Software 2978195VCT, with a 0.4 s rotation of helical acquisition, 40 mm detector coverage, 120 Kv with a 400 mAs; slice thickness of 1.25 mm, 0.984 : 1 mm/rot Pitch, and a 40 to 50 cm FOV. All patients were injected with intravenous iodinated contrast medium  at a dose of 1 to 2 ml/kg with a 3.5 ml/second injection rate. The data obtained were transferred and analyzed in Osirix Lite station in its version of 32 bits for Mac devices on OS X10.8, using multiplanar reformatting (MPR) with maximum intensity projection (MIP) and volume rendering (VR). To perform the measurements, a range of window WW: 400 and WL: 40  was used in a standardized manner for all patients taking into account the internal diameter of each artery evaluated.Imaging studies were evaluated by an experienced radiologist with prior training in the use of software and knowledge of the most commonly accepted anatomical classification .The evaluation of the bronchial arteries was performed according to the following variables: origin, branching patterns, location ostium, vertebral level source, diameter, and mediastinal trajectory in reference to the esophagus and the main bronchi.The origin of the each bronchial artery could be independent, a common trunk or an intercostobrachial trunk. In turn, these arteries of origin could originate from the thoracic aorta, the aortic arch, the subclavian arteries, internal thoracic artery, or the thyrocervical trunk. A bronchial common trunk was considered when two or more bronchial arteries originated from the primary vessel before contacting the main bronchus. The aortic arch was considered to end and the thoracic aorta to begin, at the lower border of the T4 vertebra.https://doi.org/10.1155/2017/9785896).After establishing the origin of each of the bronchial arteries, their trajectory continued until contact with the corresponding main bronchus to determine their side (left or right) and branching pattern. Patterns found were ordered according to their frequency and alphabetical letters (A–L) were designated for identification. Single frequency patterns were considered atypical and were grouped in the L category and assigned Arabic numerals pattern (L1–L24)  . ArteriePosition of each bronchial artery in relation to its mediastinal trajectory (left or right) was documented. The position (anterior or posterior) of the bronchial artery in relation to the main bronchus was determined by observing the point of first contact between the two structures.The diameter of all bronchial arteries, common trunks, and intercostobrachial trunks involved was documented at the origin of the vessel. All measurements were reported in millimeters and were stored in a database for subsequent statistical analysis.Subsequent to morphological and morphometric analysis, a statistical comparison between sides (left versus right) and gender (men versus women) for all variables was performed.U tests were performed to determine whether there was a difference between each of the qualitative variables regarding side (left versus right) and gender. Likewise, Student's t-test for independent samples was performed to assess statistical differences regarding diameter in relation to gender and side. A p of <0.05 was considered as significant.Statistical analysis was performed using the computer program SPSS version 20.0 for Windows XP. Measures of central tendency and dispersion tests were obtained by descriptive statistics for qualitative data. Nonparametric Kolmogorov-Smirnov to analyze the distribution of data was performed. Binomial tests of a sample were performed to determine whether there was a difference between the number of men and women and the number of left and right bronchial arteries. Subsequently, Mann–Whitney This study was approved by the Ethics Committee and the Research Committee of the Universidad Autónoma de Nuevo León, Facultad de Medicina, with the registration number AH14-005. No patient was radiated nor received contrast for the purposes of this study. There was no financial or commercial gain in the realization of this study, so the authors declare no conflicts of interest.p = 0.215).We evaluated 139 angiograms by CTA  from a population of Mexican patients. The mean age was 49.90 years ± 18.62 with a range between 18 and 90 years. Men had a mean age of 47.40 ± 19.05 years with a range between 19 and 90, while women had a mean of 52.67 ± 17.86 with a range between 18 and 85 years. Gender groups were distributed homogeneously  were orthotopic, 95 (54.54%) left, and 114 (45.45%) right sided. We also found 106 (33.65%) ectopic bronchial arteries, of which 69 (65.09%) were left and 37 (34.90%) right.p = 0.499). Men also had a higher number of bronchial arteries than women but it was not statistically significant (p = 0.650).We identified between 2 and 5 bronchial arteries distal to the origin per patient, with higher prevalence for the left side than the right; however this difference was not statistically significant  or on gender (p = 0.354).Bronchial arteries originated from the thoracic aorta (74.60%), aortic arch (23.49%), and other vessels (1.90%). In the aorta they emerged as independent branches (40.95%), branches from a common trunk (29.84%) , or branWe identified 35 different branching patterns . Twenty-p = 0.398) and no significant difference between genders (p = 0.872).The location of the ostium depended on the artery origin. In the bronchial arteries originating from the thoracic aorta, the location of the ostium was found mainly in the anterior-medial portion (58.29%), followed by the medial portion (13.19%) and anterior-lateral portion (10.63%). For these arising from the aortic arch, the location of the ostium was found mainly in the superomedial portion (60.81%), followed by inferior-medial (14.86%) and superior-lateral (13.51%) . There wAll bronchial arteries originated between C7 and T7 vertebral levels. Between T5 and T6 66.34% of bronchial arteries originated, 54.54% were right sided, and 45.45% were left, 55.98% were men, and 44.01% women. Above the vertebral level T5, 32.69% originated, of which 34.95% were right and 65.04% left, 48.54% corresponded to men and 51.45% to women. Below T6, the remaining 0.95% originated, 33.33% were right, 66.66% were left, 66.66% were men, and 33.33% women .p = 0.006) was identified; however there is no difference for this parameter between arteries on both sides (p = 0.997).Men had higher incidence of orthotopic bronchial arteries (55.98%) but were similar to women in ectopic bronchial arteries  . A statip < 0.001), but there was no significant difference between genders (p = 0.943).The left bronchial arteries passed in 96.95% of cases to the left of the esophagus and 3.04% to the right of the esophagus. The right bronchial arteries passed in 56.29% of cases to the right of the esophagus and 43.70% to the left of the esophagus . A signip = 0.318) and in both genders (p = 0.527) . The trajectory in relation to the main bronchus was the same on both sides (= 0.527) .p < 0.001). Significant difference was also evident between genders (p = 0.013), as men had larger diameters than women.In both genders, the luminal diameter of the bronchial arteries had a mean of 1.62 ± 0.29 mm with a range of 1.14 to 2.97 mm  . HoweverForty-six common trunks of bronchial arteries were identified in 46 patients, of which 28 (60.86%) originated from the thoracic aorta, 17 (36.95%) from the aortic arch, and one (2.17%) originated from a left thyrocervical trunk. For those originating from the thoracic aorta, the ostium location was primarily in the anteromedial portion (53.57%), and for those from the aortic arch the ostial location was primarily in the superomedial portion (64.70%). In the thoracic aorta originated, 60.71% originated at the vertebral level T5, and in the aortic arch 76.47% at the vertebral level T4. The common trunk that originated from the left thyrocervical trunk has a vertebral level of C7-T1. The mean diameter was 1.82 ± 0.35 mm (range 1.19 to 2.69 mm).The common trunks gave rise to 94 bronchial arteries, of which 43 were right (45.74%) and 51 left (54.25%). In 40 cases (86.95%), it was the origin for one left bronchial artery and one right bronchial artery. In 4 cases (8.69%) it branched one right and two left bronchial arteries, and in 2 cases (4.34%) two left bronchial arteries  originated in the thoracic aorta and 6 (7.22%) in the aortic arch. The ostium localization was found predominantly in the anterior-medial portion (54.54%) in the ones originating from the thoracic aorta and in the inferior-medial portion (50%) for the ones originating in the aortic arch. The vertebral level was T5 (62.33%) and T4 (100%), respectively, with a mean luminal diameter of 1,99 ± 0.40 mm (range 1.32 to 3.21 mm).The intercostobrachial trunks gave rise to a total of 86 bronchial arteries, of which 80 (93.02%) were right and 6 (6.97%) left  except the mediastinal trajectory reference to the esophagus and lumen diameter. The data presented in this study demonstrated that the branching patterns of bronchial arteries and their frequencies reported in the literature do not coincide with results from a Mexican population. Further studies using higher resolution imaging techniques are needed to study the morphology of the bronchial arteries.Supplementary Figure 1: This contains the 35 branching patterns of bronchial arteries. Left lower letter indicates the corresponding pattern described in our study and the right lower number corresponds to the classification by Cauldwell et al. (a line means the pattern was not included in the Cauldwell classification). Center lower number represents the total frequency with male and female reported between parenthesis .Supplementary Figure 2: This contains a special case of the branching pattern “K” of the bronchial arteries.Supplementary Figure 3: This contains a special case of the branching pattern “L2” of the bronchial arteries.Supplementary Figure 4: This contains a special case of the branching pattern “L21” of the bronchial arteries.


In early breast cancer, the optimal technique for sentinel lymph node biopsy (SLNB) is the combined technique (radioisotope and Patent Blue V) which achieves high identification rates. Despite this, many centres have decided to stop using blue dye due to blue-dye-related complications . We evaluated the SLNB identification rate using the combined technique with and without Patent Blue V and the blue-dye-related complication rates.Clinical and histological data were analysed on patients undergoing SLNB between March 2014 and April 2015. SLNB was performed following standard hospital protocols using the combined technique.n = 158/160), with blue dye alone 92.5% (n = 148/160) and with radioisotope alone 97.5% (n = 156/160). A total of 76.9% (263/342) of nodes were radioactive and blue, 15.5% (53/342) only radioactive and 2.3% (8/342) only blue, 5.3% (18/342) were neither radioactive nor blue. No anaphylactic reactions were reported and blue skin staining was reported in six (3.8%) patients.A total of 208 patients underwent SLNB and 160 patients (342 nodes) with complete operation notes were available for final analysis. The identification rate with the combined technique was 98.8%  has comparable sentinel node identification rates in experienced hands. National guidelines are required to optimise operative documentation. In early breast cancer, sentinel lymph node biopsy (SLNB) is the preferred method for axillary staging –2. SLNB The combined technique using both radioactive TcM99m and blue dye is the current golden standard for SLNB –6. IdentDespite the recognised superiority of the dual technique over radioisotope alone, many centres have decided to stop using blue dye due to blue-dye-related complications  or lack of licensing for blue dyes –13. We eClinical and histological data were evaluated on patients undergoing SLNB between March 2014 and April 2015. This study was approved by the Clinical Review Board (ref 5320).All patients who underwent SLNB for newly diagnosed breast cancer were included. In the case of a bilateral SLNB, only the side with the highest grade, largest primary tumour size or most involved nodes was included to avoid confounding variables.Patients were excluded if there was no procedure description available in operative or pathology notes, if only an injection of radioisotope or Patent Blue V was administered, or if the colour or radioactivity within nodes was not documented.ex vivo. Operation notes included the amount of Patent Blue V injected, amount of nodes excised and if these nodes were blue and/or radioactive. A successful SLNB was defined as a procedure in which at least one true sentinel node was identified to be either blue and/or radioactive.All SLNB procedures were performed using radioisotope, Patent Blue V and a scrubbed consultant surgeon. Patients scheduled to undergo SLNB in the Breast Unit at Guy’s and St. Thomas’ NHS Foundation Trust were injected with radioisotope on the morning of surgery either at the Nuclear Medicine Department or in Day Surgery Unit. Prior to surgery, Patent Blue V was injected peri-areolarly on table followed by a massage of the injection site. During SLNB, the surgeon used a gamma probe to detect the radioisotope and visually identified blue nodes. Any nodes with a count of 10% or more of the highest node count were excised. Beyond four nodes, surgeons excised additional nodes only at their discretion and noted the background count on completion. Palpable nodes felt during the procedure were also removed. For every excised node, the gamma probe was used to determine the radioactivity of nodes All excised SLN’s were sent for histopathological evaluation in accordance with national protocols. Nodes were reported as either normal or involved containing isolated tumour cells (ITC) (≤ 0.2 mm), micrometastases (> 0.2 and ≤ 2.0 mm) or macrometastases (> 2.0 mm). The size of the largest deposit was also reported by the pathologist.p = 0.97, we were prepared to accept non-inferiority with a margin of δ = 0.05. The probability that the addition of radioactivity results in finding new nodes is r0 = kδ with k = 0.2. With 90% power and a 95% one-sided confidence level, zα is the standard normal variate value corresponding to the test size, zα = 1.6449 and zβ the variate corresponding to the test power, zβ = 1.2816. Using the following formula gives a sample size of N = 148 patients.To statistically determine whether SLNB with Patent Blue V provides a non-inferior identification rate compared to the combined technique, a sample size calculation was performed. With an identification rate for the combined technique of p the identification rate of the combined technique. The probability of detecting a node with blue dye or with radioisotope alone should not be lower than p-δ. [A non-inferiority test was performed to define whether the blue dye technique alone is non-inferior to the combined technique using δ = 0.05 and han p-δ. –15t-test. For tumour grade, lymph node status, the presence of lymphovascular invasion, ER/HER2 status, and surgeon’s experience, we performed a crosstab and Fisher’s exact test. We repeated the analysis for sentinel node identification with the combined technique, radioisotope alone, and blue dye alone.To evaluate potential differences in sentinel node identification with different tumour size and volume of blue dye, we performed an independent A total of 208 patients underwent SLNB between March 2014 and April 2015. In the 48 patients who were excluded, operation notes were incomplete in 38 patients (18.3%) and operation notes were missing in eight patients (3.8%). One patient (0.5%) was excluded because she only received Patent Blue V and one patient (0.5%) only received radioisotope. A total of 160 patients in which 342 nodes (range 1–6 nodes) removed were available for final analysis. Patient and tumour characteristics are tabulated in About 78.8% (126/160) procedures were performed by specialised breast surgeons who have over 10 years of experience and 21.2% (34/160) were performed by fellows specialised in breast surgery.In 80 cases (50.0%), SLNB’s were performed on the left and 80 cases (50.0%) on the right. There were 12 cases (7.5%) of bilateral SLNB. SLNB was performed in combination with a mastectomy in 47 cases (29.4%), wide local excision (WLE) in 89 cases (55.7%), and re-excision in five cases (3.1%). In 19 cases (11.9%), an SLNB alone was performed.In 24 cases (15.0%), 1.0 ml of Patent Blue V dye was injected, 2.0 ml was injected in 70 cases (43.8%) and the volume of injected Patent Blue V dye was not documented in 66 cases (41.2%). All 1.0 ml injections were not diluted apart from one which was diluted with 2.0 ml of saline. About 40% (28/70) of 2.0 ml injections were not diluted and 60% (42/70) were diluted with 3.0 ml of saline.n = 158/160), with blue dye alone 92.5% (n = 148/160) and with radioisotope alone 97.5% (n = 156/160) (The sentinel node identification rate with the combined technique was 98.8% (156/160) . In two The extra number of nodes detected by radioisotope was 6.3% ) using the normal approximation of Agresti and Coull . The comt-test found no statistically significant difference in sentinel node identification between patients with different tumour size and volume of blue dye injected. For tumour grade, lymph node status, the presence of lymphovascular invasion, ER/HER2 status and surgeon’s experience, Fisher’s exact test found no statistically significant differences with sentinel node identification.An independent In 158 patients who underwent successful SLNB, a total of 333 sentinel lymph nodes were excised, a mean of 2.1 nodes per patient. One node was excised in 47 patients, two nodes in 68 patients, three nodes in 25 patients, four nodes in 16 patients, five node in one patient and six nodes in one patient. These nodes were both radioactive and blue in 263 nodes (79.0%), only radioactive in 53 nodes (15.9%), only blue in eight nodes (2.4%) and neither radioactive nor blue in nine nodes (2.7%) .The patients with sentinel lymph nodes not detected by blue dye were injected with 1 ml of blue dye , 2 ml , or the amount was not mentioned . Patients with nodes not detected by either blue dye or radioisotope were injected with 1ml of blue dye , 2 ml  or this was not mentioned .The two patients with a failed SLNB had nine nodes excised after injection of 2 ml blue dye  or this was not mentioned .On histopathological examination, 35 patients (16.8%) had involved lymph nodes, 15 patients (9.4%) had micrometastases and 20 patients (12.5%) had macrometastases . In thesOf 18 nodes with micrometastasis, 15 (83.3%) were both radioactive and blue and three (16.7%) were only radioactive. Of 25 nodes with macro-metastases, 18 nodes (72.0%) were both radioactive and blue, six nodes (24.0%) only radioactive and one node (4.0%) only blue . Therefon = 33), haematoma (n = 6), breast oedema (n = 2), infection (n = 2), erythema (n = 1), reduced shoulder movement (n = 1), pain (n = 1), a candida infection (n = 1) and an undocumented complication (n = 1).Post-operative complications were seroma (n = 6/160) of patients which successfully underwent SLNB and no anaphylactic reactions related to blue dye were reported.Blue staining of the skin was reported in 3.8% . Documentation of retrieval of blue or radioactive nodes confirms if the SLNB procedure was successfully completed. There are currently no national  guidelines describing the minimal data set required for the documentation of SLNB procedures. SLNB carries a 6–10% false-negative rate when performed using the standard combined technique, it is likely to be higher if the combined technique is not used with consequently lower identification rates. In this study, the false negative rates for blue dye and radioisotope were 21.4% and 2.9%, respectively. However, no axillary node clearance was performed, to be able to obtain the correct false-negative rate for both techniques. In order to be able to audit SLNB identification rates, it is essential to know the number of nodes removed, their colour and radioactivity count. Guidelines are needed to ensure standardised administration of blue dye and adequate documentation of these procedures, including the type, amount, and dilution of tracers used.Blue dye causes a tattoo at the site of injection and carries a 0.6% risk of anaphylaxis. Complications due to blue dye may be underreported due to inadequate documentation. In this study, a blue tattoo was only reported in 3.8% (six patients) suggesting this is significantly under-reported as it is often asymptomatic. Furthermore, the blue staining was only reported up to three weeks after SLNB, without documentation of resolution. With the increased number of patients suitable for SLNB, it is important to reduce the risk of blue-dye-related complications. In order to understand the impact of the issue, correct documentation is necessary. Therefore, there should be greater emphasis on standardisation of surgical techniques.With respect to nodal involvement the combined technique should be used since if only the radioisotope or blue dye techniques are used alone, involved nodes would have been missed . The limIn the search for new SLNB techniques, it will be difficult to find a technique with an identification rate superior to that of the combined technique in view of its very high identification rate. However, if we can develop a single agent or device that can accomplish the same level of accuracy and rule out the use of radioisotopes, it is likely that the combined technique will be replaced. Currently, several new techniques are under investigation, including the magnetic technique, using superparamagnetic nanoparticles and a hand-held magnetometer, showing an identification rate between 94.4% and 98.5% , 18, 19 The combined technique should continue to be the preferred technique for SLNB and should be standardised. Radioisotope alone  has comparable sentinel node identification rates in experienced hands. National guidelines are required to optimise operative documentation.ALNDAxillary lymph node dissectionSLNBSentinel lymph node biopsyWLEWide local excisionITCIsolated tumour cells“The author(s) declare that they have no conflict of interest.”


Adult granulosa cell tumors (AGCTs) are the most common sex cord-stromal tumors. Unlike epithelial ovarian tumors, they occur in young women and are usually detected at an early stage. The aim of this study was to report the clinical and pathological characteristics of AGCT patients and to identify the prognostic factors. All cases of AGCTs, treated at Salah Azaïz Institute between 1995 and 2010, were retrospectively included. Kaplan-Meier's statistical method was used to assess the relapse-free survival and the overall survival.n = 19). Mean tumor size was 20 cm. The majority of patients had a stage I disease . Two among 3 patients with stage IV disease had liver metastasis. Mitotic index was low in 45% of cases (n = 14). Surgical treatment was optimal in almost all cases . The median follow-up time was 14 years (1–184 months). Ten patients relapsed (32%) with a median RFS of 8.4 years (6.8–9.9 years). Mean overall survival was 13 years (11–15 years). Stage I disease and low-to-intermediate mitotic index were associated with a better prognosis in univariate analysis  but were not independent prognostic factors. The final cohort included 31 patients with AGCT. The mean age was 53 years (35–73 years). Patients mainly presented with abdominal mass and/or pain (61%,  GCTs have a long natural history with common late relapses. Hence, long active follow-up is recommended. In Tunisian patients, hepatic metastases were more frequent than occidental series. The prognosis remains good and initial staging at diagnosis is an important prognostic factor.  Granulosa cell tumors (GCTs) represent only 5% of all ovarian cancers. However, they are the most common subtype of ovarian sex-cord tumors (70%) .They first were reported by Rokitanski in 1855 . AlthougHyperoestrogenism reported in patients with GCT is related to tumor production of oestrogens, anti-Müllerian hormone, and inhibin B . AccordiWe conducted a retrospective single-center cohort study of all patients with AGCT diagnosed and treated in the Medical Oncology Department at Salah Azaïz Institute for cancer from 1995 to 2010. Quantitative variables were expressed as mean and median values. Qualitative variables are expressed as absolute and relative frequencies. Statistical analyses were performed using SPSS 20.0 software. Kaplan-Meier's statistical method was used to assess the recurrence-free survival and overall survival .n = 19). Postmenopausal bleeding was reported in 32% of cases (n = 10). Ultrasound imaging was performed in all cases and showed mainly cystic unilateral mass (80%  n = 25). Median tumor size was 20 cm (4–33 cm). Abnormally elevated levels of serum tumor marker CA-125 were reported in 42% of patients (n = 13). Inhibin B was not studied in any of our patients.A total of 31 women with a mean age of 53 years (35–73 years) were included in the study. 61% of cases presented with abdominal mass and/or abdominal pain in , Call-Exner bodies (55%), and necrosis (22%). Mitotic index measured in only 22 patients was mainly low (64%). The staging breakdown was as follows: stage I represents 61% (stage IC: 58% of stage I), stage II 10%, stage III 19%, and stage IV 10%. Metastases locations were mainly liver (67%) and pleura (33%). The primary treatment was surgery in all cases. 28 patients (90%) underwent hysterectomy with bilateral salpingo-oophorectomy. Nonoptimal surgery was reported in 3 cases (10%). Intraoperative tumor rupture occurred in 5 patients (16%). Adjuvant treatment was chemotherapy followed by hormonal therapy in one woman (3%) and chemotherapy alone in 18 women (58%). No patient received adjuvant radiotherapy.Adjuvant chemotherapy was a platinum-based regimen: cyclophosphamide-cisplatin in 13 patients (72%) and bleomycin-etoposide-cisplatin in 6 patients (28%).Mean overall survival was 13 years (11–15 years). Overall survival at 10 years was 90%.p = 0.04) and the median OS was 46.3 months versus 42 months (p = 0.01), respectively (p = 0.01). No independent prognostic factor was identified in the multivariate analysis.The median follow-up time was 14 years (1–184 months). Median RFS was 8.4 years (6.8–9.9 years). Relapses were reported in 10 patients (32%); among them, 6 had local recurrence (60%). Characteristics of these patients are shown in ectively . High miAGCT is a very rare tumor with a known good prognosis. In fact, only 31 patients were included in our study from 1995 to 2010, and this is the first published study conducted in a Tunisian population.Since it is a rare disease, limited data are available . ClinicaThe most reported signs in the literature are abdominal pain and/or abdominal distension 30% to 50%) and hormonal event such as postmenopausal bleeding, amenorrhea, and intermenstrual bleeding . The siz0% and hoThe mainstay of treatment is a complete surgery  with staging for early stage and debulking surgery for advanced stage or recurrent disease .Fertility-preserving surgery with unilateral salpingo-oophorectomy is an option in young patients with stage IA GCT. Available data showed that there is not much difference in survival with a conservative approach when compared to the radical surgery . The 5-year and 10-year disease-specific survival was 97% and 94% [Chemotherapy is recommended for patients with advanced stage and recurrent disease. In early stage GCT, only high risk patients  should receive adjuvant chemotherapy .The most used chemotherapy regimen is a BVP  or a BEP regimen, which substitutes etoposide for vinblastine . HormonaThe majors factors suspected in a number of studies were age, tumor size, rupture of tumor, mitotic activity, nuclear atypia, aneuploidy (in 5–20% GCT), p53 overexpression, high Ki-67, and stage of the disease . Similarp = 0.04). Our study too presents the same limitations as it is retrospective and included a small number despite its spread over 15 years.The same survival rates were found in our study with a significant prognostic value of stage as OS at 5 years was 98% in early stage and 65% in advanced stage (p = 0.01).Patients whose tumors had a mitotic index < 4/10 HPF had a DFS at 80 months of 90% compared to 25% for patients with a higher mitotic index . These dp = 0.015) [p = 0.325) [Discording data were reported regarding the prognostic value of age, tumor size, residual disease, and tumor rupture. In fact, Ayhan et al. found that patients aged below 60 years had better mean time of survival  . Some st= 0.015) . Thomakop = 0.05). In case of tumor rupture, OS at 5 years was 68% versus 76% in other cases (p = 0.22).In Ranganath et al.'s study, median survival of GCT patients who underwent optimal cytoreduction was 60 months in contrast to 19 months for those who did not with a decrease in survival from 82% to 22% . Tumor rIn the light of Ala-Fossi et al.'s study findings, P53 mutation in GCT may be associated with poor prognosis .GCTs have a tendency for late recurrence. The recurrence rate in our study was 32%, whereas it was 44% in Wu et al.'s study. In this letter, early relapses were significantly related to advanced stage . The lonLocal pelvic recurrence was reported in 70% of cases; only 9% of recurrences were abdominopelvic, 6% were retroperitoneal, 6% were pelvic and retroperitoneal, and 3% were abdominopelvic and retroperitoneal . In our Multidisciplinary treatment approach usually consists of disease debulking followed by radiotherapy or chemotherapy and may prolong the DFS . Brown eGranulosa cell tumor is an uncommon ovary neoplasm. It is known for relapsing even years after a curative treatment. Hence, an active lifelong follow-up is recommended with clinical examination and tumor markers such as inhibin B . Disease


The incidence of type 2 diabetes mellitus (T2DM) has been increasing globally over the past two decades in children and adolescents. There are currently a dearth of comprehensive population-based estimates of T2DM incidence and time trends in Chinese youth.A population-based diabetes registry system in 30 representative districts in Zhejiang has been established for diabetes surveillance. All newly cases diagnosed by physicians in local hospitals and wards were registered using the registry system through web services and direct network report. The data were primarily abstracted from medical records in hospitals and wards. Annual incidence rates and their 95% confidence intervals (CIs) by age groups and sex were calculated per 100 000 person-years. Poisson regression models were applied to assess the effects of diagnosis year, age groups, sex and residence area on T2DM incidence and to examine the average annual percentage change in incidence.There were 392 newly diagnosed cases of T2DM (210 boys and 182 girls) over the study period. The mean annual age-standardized incidence was 1.96/100 000 person-years (95% CIs: 1.85–2.08). No statistically significant difference in incidence was found between boys and girls. However, the risk for T2DM was 1.49 times higher in urban area than in rural area. Besides, the mean annual incidence in youth increased with age. The age-standardized incidence was about 5 times higher in 2013 than in 2007. Steep rising incidence was observed, with an average annual increase of 26.6% in youth aged 10–19 years.The incidence of T2DM in children and adolescents was low in Zhejiang relative to other countries, whereas it increased markedly over the study period. Preventive strategies for T2DM are necessary in pediatric population. Type 2 diabetes mellitus (T2DM) was traditionally considered to be a serious chronic medical condition only for adults. However, increasing incidence of T2DM in children and adolescents has been noted in both developed and developing countries in recent decades –4. PreviIn spite T2DM was still relatively uncommon in youth, the China Health and Nutrition Survey (CHNS) noted that the prevalence of diabetes was already higher in Chinese adolescents than in US adolescents and the comparisons of diabetes across China, South Korea and Taiwan also suggested higher diabetes prevalence in China . There aZhejiang, one of the most economically prosperous coastal province in China, consists of 90 districts. A prospective population-based diabetes registry system maintained by Zhejiang Provincial Center for Disease Control and Prevention (CDC) has been established for diabetes surveillance in 30 representative districts, covering a population about 16.6 million people.All newly cases diagnosed by physicians in local hospitals and wards were registered using the registry system through web services and direct network report. In present study, cases were defined as children and adolescents diagnosed as T2DM aged 5–19 years, with a date of diagnosis between 1 January 2007 and 31 December 2013. All cases had elevated blood glucose at least one of the following criteria according to WHO criteria : (1) ranThe registering data were primarily abstracted from medical records in hospitals. Each individual registered in our system documented the basic properties of hospital, the patients’ demographic characteristics, the physician diagnosis and a unique study identification number, etc. In order to ensure our investigation in a homogeneous population of the surveillance districts, we excluded cases that not registered in local resident information system of the 30 surveillance districts based on resident identity number. The data were cleaned up and duplicates within or between the different reporting institutions were identified. Population data of surveillance districts estimated at the end of each year were obtained from Zhejiang Provincial Statistics Bureau by sex, age groups, area of residence and calendar year. The definition of urban and rural areas was based on administrative division in Zhejiang. The main difference was whether the economic activity in regions dominated by agriculture.Completeness of ascertainment was verified using an alternative source of cases recruited from the under-reporting surveys which was an independent survey aimed at evaluating the degree of ascertainment. The registry system provided data for the primary source, and the under-reporting survey provided data for the secondary source. The completeness of ascertainment was calculated according to two-sample capture-recapture method . This stThe numerator of crude incidence rates were expressed as the number of newly diagnosed cases pooled across all 30 surveillance districts using data from both sources combined. The population registered in local resident information system was regard as denominator. The incidence were calculated separately for three age groups at diagnosis: 5–9, 10–14 and 15–19 years, and also according to sex. The 95% confidence intervals (CIs) were estimated on the basis of inverting the score test for a binomial proportion [P-values < 0.05 were considered statistically significant.After checking that there was no over-dispersion in the data, Poisson regression models were applied to assess the effects of diagnosis year, age groups, sex and residence area on incidence and to examine the average annual percentage change in incidence. Results were reported as incidence rate ratio (IRR) with 95% CIs. The exponent of the Poisson regression coefficients and corresponding standard errors were used to derive IRR and their 95% CIs, which provides a measure of the relative incidence of T2DM in one population group  compared with another group . Interactions between diagnosis year and age group, sex, residence area were tested to investigate whether changes over time are consistent within these covariates. To examine trends in diabetes incidence across the study period, we treated the calendar year as a continuous variable and tested the statistical significance of the regression coefficient. Statistical analyses were performed using SAS PROC GENMOD . A total of 392 children and adolescents aged 5–19 years were diagnosed with T2DM (210 boys and 182 girls) during the study period. Using the two-sample capture-recapture method, the completeness of ascertainment for the whole period in all sites was estimated to be 90.5%. The crude mean annual incidence over the 7 years was 1.73/100 000 person-years (95% CIs: 1.56–1.91). Standardized mean annual incidence for the same period was 1.96/100 000 person-years . However, the risk for T2DM was 1.49 times  higher in urban area than that in rural area (Table The crude mean incidence in boys was 1.81/100 000 person-years (95% CIs: 1.57–2.07) and in girls 1.65/100 000 person-years (95% CIs: 1.42–1.91). Standardized mean annual incidence for the same period was 2.07/100 000 person-years (95% CIs: 1.91–2.24) in boys and 1.85/100 000 person-years (95% CIs: 1.69–2.01) in girls (Table P < 0.001), ranged from 0.11/100 000 person-years (95% CIs: 0.03–0.28) to 4.30/100 000 person-years (95% CIs: 3.69–4.98) in boys, and 0.06/100 000 person-years (95% CIs: 0.01–0.22) to 3.58/100 000 person-years (95% CIs: 3.02–4.21) in girls. The highest incidence was in 15–19 years age group, i.e., 3.94/100 000 person-years (95% CIs: 3.52–4.40), followed by 10–14 years, i.e., 0.85/100 000 person-years (95% CIs: 0.65–1.08). The least incidence was 0.09/100 000 person-years (95% CIs: 0.03–0.19) in 5–9 years age group  in US was 7.0/100 000 person-years in youth aged 5–19 years between 2002 and 2003 . MoreoveIn our study, the age-standardized incidence was about five times higher in 2013 than that in 2007, with an average annual increase of 26.60% in 10–19 years of age. This was considerably greater than data from other worldwide population. In New Zealand, the incidence of T2DM increased by five-fold during 1995 to 2007 in children and adolescents . AdditioT2DM is a complex metabolic disorder of heterogenous etiology with social, behavioral, and environmental risk factors unmasking the effects of genetic susceptibility . DespiteDuring the study period, a faster annual increasing was identified in boys and rural area, and the average annual percentage change decreased with age in the point estimation of Poisson regression models. Similarly, a study in west Yorkshire, UK reported a faster increase for children aged 0–14 (37.4%) compared with those aged 15–19 (18.1%) between 1991 and 2006. . The resThe present study showed the mean annual incidence in youth increased with age. The results consisted with SEARCH project in US, in which the overall annual incidence rate per 100 000 person-years were 0.8, 8.1 and 11.8 for 5–9, 10–14 and 15–19 years age group, respectively . The pheDespite the age-standardized incidence was higher in boys than in girls, no statistically significant difference was observed. Similar to our results, there were no statistically significant difference between sex in Japan and US Virgin Islands’ reports , 20. HowThe diabetes registry system was the primary source of data on the incidence and trends of diabetes in the territory. We utilized data from medical records to update the registry. This presented several limitations for consideration. First, in the earlier time points, people did not go to hospital until they had obviously clinical manifestations, meanwhile, there were no routine physical examinations for them. Therefore, the diagnosis time may be delayed and it was difficult to estimate the fraction of undiagnosed diabetes without related screening. As frequent mild or asymptomatic manifestation of T2DM in childhood , 33, ourThis study examined the incidence rate and time trends of T2DM over a 7 year period in a population-based registry in Zhejiang, China. An alarming increasing in incidence was observed, although the overall incidence was low relative to other countries. The mean annual incidence in youth increased with age. Children and adolescents living in urban area had a greater risk of T2DM compared with those living in rural area. Preventive strategies for T2DM are necessary in pediatric population.