Campylobacter infections in England and Wales during 1990–2007, we analyzed electronic laboratory data. Disease incidence was reduced among children, and the greatest increase in risk was for those >60 years of age. Risk factors for campylobacteriosis in the elderly population should be identified.To explore hypotheses for age-related changes in the incidence of  Campylobacter infection remains a major public health problem worldwide. The infection is unpleasant, although generally self-limiting, and most patients experience acute enteritis for 7–10 days . This increase was largely artifactual, reflecting increased scientific interest in, and testing for, Campylobacter spp. and improvements in media and methods for isolating them  and stored in a Microsoft Access  database. Cases were assigned to 10-year age groups and to geographic areas on the basis of laboratory location . The season was assigned on the basis of the earliest available specimen date . Data on cases of cryptosporidiosis and nontyphoidal salmonellosis for the same period were extracted, grouped, and categorized and manipulated as above for comparative purposes. Denominator data for England and Wales for the same period were obtained from the Office for National Statistics. Data were analyzed in Microsoft Excel 2003 and Stata version 10 . Estimates of incidence per 100,000 population were calculated throughout; relative risks (RR) and 95% confidence intervals (CIs) were calculated as required.Data on all Campylobacter infection were reported; patient age was available for 810,632 case-patients (96.7%). From 1990 through 1999, incidence increased in all age groups (>60 years RR 2.51 [95% CI 2.41–2.61]). From 2000 through 2004, incidence declined in all age groups. However, although the degree of decline was similar for those 0–9 years of age (RR 0.77 [95% CI 0.74–0.8]), 10–19 years (RR 0.73 [95% CI 0.70–0.76]), and 20–59 years (RR 0.75 [95% CI 0.74–0.76]), for patients >60 years of age, the degree of decline was significantly lower . Finally, although the incidence increased only moderately among those 10–19 years of age (RR 1.02 [95% CI 0.98–1.07]) and 20–59 years (RR 1.04 [95% CI 1.03–1.06]) from 2005 through 2007, greater increases were observed for those 0–9 years (RR 1.12 [95% CI 1.08–1.17]) and those >60 years (RR 1.33 [95% CI 1.29–1.36]). During the surveillance period, therefore, the incidence among patients >60 years of age, compared with the incidence among younger patients, increased markedly (RR 0.45 [95% CI 0.44–0.47] in 1990 to RR 1.17 [95% CI 1.15–1.19] in 2007). This effect was observed for campylobacteriosis in both sexes, in 3 geographic areas of England and Wales, and in all 4 seasons, but was not observed for nontyphoidal salmonellosis or cryptosporidiosis  are more often associated with coexisting conditions that might occur more frequently in the elderly. This circumstance was unlikely to have affected the results of this study, however. First, isolation methods used in England and Wales favor the growth of C. jejuni and C. coli , from 2000 through 2004 , and from 2005 through 2007  .When disease incidence was ranked according to specific population group, children 0–9 years of age had the highest ranking in 1990, but by 2007, incidence for this age group ranked seventh of 9 age groups. Incidence among children <10 years declined most rapidly from 1998 to 2003. This finding led to the hypothesis that the introduction and increased utilization of the National Health Service’s NHS Direct  at this time had a “triage effect” on those seeking care for children in this age group. The 2 events are correlated in time , the overall trend singles them out as the main emerging at-risk group . The pattern of infection in older patients is perhaps predictable, given the similar pattern for incidence of listeriosis in England and Wales since 2001 (Relative incidence of Campylobacter infection in each year compared with that in 1990 among patients >60 years of age infected with selected gastrointestinal pathogens, England and Wales, 1991-2007


We aimed to assess the survival of older patients after admission to critical care compared with the population in general.We reviewed admission data for a 12-bed critical care unit in a district general hospital in the UK between 2001 and 2010. We calculated critical care and hospital discharge survival rates and studied the trend in these through the decade. We searched hospital records to establish whether these patients were still alive at November 2012 to determine life-expectancy . This was compared with UK Office of National Statistics data for the local population [A total of 481 patients aged 80 or over were admitted between 1 January 2001 and 31 December 2010, representing 9.6% of the admissions during this time with minimal annual change. Admission age ranged from 80 to 96 years (median 83) with a median APACHE II score of 20 . In total, 318 (66.1%) survived to critical care discharge and 256 (53.2%) survived to hospital discharge; 228 (89.0%) went home rather than to a care facility. Those under 80 years demonstrated 80.6% critical care survival, 65.5% hospital survival and a median APACHE II score of 17 . Eighty patients died within the 22-month follow-up period with an average life expectancy of 7.4 months. None reached life expectancy (average curtailment of 5.6 years compared with age-matched and sex-matched population statistics). Neither of these figures changed significantly through the decade. However, 10-year follow-up on 2001/2002 admissions showed that, despite this early mortality effect, the average post-discharge lifespan was 5.1 years with 2.2 years shortfall in life expectancy.Older people represent a growing proportion of the population although their representation in the critical care population remained constant in this 10-year study. These patients had a slightly higher median APACHE II score and 14.5% greater critical care mortality than the younger patients. The majority of survivors were able to go home; however, 31% died within 22 months with significant life expectancy curtailment, surviving on average only 7.4 months after discharge; this has not changed in the last 10 years. Those who survived this initial period (69%) had a much better outlook. This information may be vital to patients and physicians when discussing admission to critical care.


Bacground. Psoriasis is an erythematosquamous dermatosis of chronic development. In sub-Saharan Africa, few studies have been focused on complicated forms of psoriasis. Objective. The aim is to describe epidemiological, clinical, and histological features of severe skin forms of psoriasis in Cote d'Ivoire. Material and Methods. The study was both cross-sectional and descriptive, that focused on patient admitted to the dermatology unit for complicated psoriasis, from January 1st, 1986, to December 31th, 2007. Results. Fifty-six patients admitted to hospital for severe skin forms of psoriasis were recorded and included in our study over 7.503 patients hospitalized during the study period. They represented 0.75% of cases. The average age was 39.6 ± 3.3 years. There were 49 male (87.5%) and 7 female patients (12.5%) with a sex ratio of 7. At socioprofessional level, 48 patients (87.5%) were from category 1. Patients' history was dominated by the psoriasis vulgaris. Physical and general signs were dominated by itching (58.9%). The three severe skin forms were observed with predominant erythrodermic psoriasis (60.7%). Fifteen patients (34.9%) were HIV positive. Conclusion. Severe skin forms of psoriasis are rare in our setting. But in the quarter of HIV-positive patients, they are dominated by the erythrodermic psoriasis. Psoriasis is an erythematosquamous dermatosis of chronic development. It is ubiquitous and seems common in the West where prevalence rate ranges from 2 to 3% in the population at large , 2. The The study was cross-sectional and descriptive. It focused on all the records of patients admitted to the Dermatology Unit of Treichville University Hospital for complicated forms of psoriasis in the period covering January 1, 1986, to December 31, 2007.In the study records of patients of all sexes and ages suffering from erythrodermic psoriasis, universal psoriasis, or pustular psoriasis confirmed by histology were included. The histological examination has been carried out in the anatomopathology labs of Treichville University Hospital on a sample of the skin lesion biopsy. The sample was stored in 10% formalin. Paraffin inclusion was performed before examining under an optical microscope.Epidemiological, clinical, and histological data along with HIV status have been recorded in a prescribed survey form.Category I: patients with monthly pay lower than the index-linked guaranteed minimum wage in Côte d'Ivoire .Category II: medium ranking civil servants of Ivorian public civil service with an average wage of 137 Euros [Category III: patients with more than 300 Euros as monthly wage.The socioprofessional status has been subdivided into three categories.Data analysis has been performed with the software Epi info 6.04 and has consisted in calculating the rates.We selected 56 records of patients suffering from complicated forms of psoriasis out of a total of 7503 hospitalization records during the 22-year study period representing 2.5 cases per year. Cumulative incidence of complicated forms of psoriasis was 0.7%. There were 49 male (87.5%) and 7 female patients (12.5%) which equals a sex ratio of 7. Average age was 39.6 ± 3.3 years with extremes of 4 and 77 years. There were 3 children (5.3%) and 53 adults (94.7%). From the adults, 38 patients (67%) were between 30 and 50 years old. At socioeconomic level, patients earning a monthly income less than 53.8 Euros accounted for 85.7% of cases. Our patients' history was dominated by psoriasis vulgaris in 21 cases (37.5%) followed by medication use in 18 cases (32.1%), tobacco in 14 cases (25%), alcohol in 14 cases (25%), combination of tobacco and alcohol in 8 cases (14.3%), stress in 3 cases (5.3%), and other variables in 7 cases (12.5%). Benzathine-penicillin and non steroidal topical remedies were the most used medecine in respectivily 22% of cases. Three severe forms have been observed. There were erythrodermic psoriasis in 34 cases (60.7%), universal psoriasis in 21 cases (37.5%), and generalized pustular psoriasis in 1 case (1.8%). Physical and general signs were dominated by itching in 33 cases (58.9%) . Ungual The severe psoriasis is rarely seen in the Dermatology Unit of Treichville University Hospital. This rareness has been reported by Kundakci et al.  in the TIn our study, the severe psoriasis observed in adults may provide a proof of a late start of the (type II) disease in relation to non pustular clinical forms . More thThe stress may be another contributor likely to lead to psoriasis outbreak or worsen an existing one according to some authors , 11, 14.Although they are scarce, severe forms of psoriasis are a concern to practitioners for being more often life-threatening because of the biological disorders and infectious complications they involve. Incidence of these severe cases of psoriasis in HIV-positive patients requires systematic HIV testing.


Dupuytren’s disease (DD), commonly affecting European men, is generally treated with surgery.Orthopaedic and plastic surgeons who had been practicing for >3 and <30 years and operated on ≥5 patients with DD between September and December 2008 were surveyed in 12 European countries . The survey assessed procedures performed, factors influencing choice of procedure, use of physical therapy and recurrence. Descriptive statistics are reported.A total of 687 surgeons participated, including 579 orthopaedic and 108 plastic surgeons; 383 (56%) were hand surgeons. About 37% of surgeons performed percutaneous needle fasciotomy (PNF), 77% fasciotomy, 95% fasciectomy and 40% dermofasciectomy (DF). Surgeons’ choice of procedure was influenced by patient preferences, age, degree of contracture and recurrent disease. The percentage of surgeons prescribing physical therapy and the mean (standard deviation [SD]) duration of therapy increased with procedure complexity: PNF = 82%, 5.2 (3.9) weeks; fasciotomy = 94%, 5.3 (3.6); fasciectomy = 97%, 6.7 (5.1); and DF = 99%, 8.5 (6.4). Using survey responses, mean (SD) estimated recurrence rates decreased and estimated time to recurrence increased with procedure complexity—PNF = 44% (27%), 17 (15) months; fasciotomy = 30% (24%), 20 (18); fasciectomy = 20% (17%), 29 (23); and DF = 20% (19%), 33 (27).Across Europe, patient and surgical factors influence the intention to use a surgical procedure. Fasciectomy was the most commonly performed procedure type and was associated with lower recurrence than PNF or fasciotomy.The online version of this article (doi:10.1007/s12570-012-0091-0) contains supplementary material, which is available to authorized users. Dupuytren’s disease (DD) is often treated surgically , 2. In EA number of different procedures are available for the surgical treatment of DD, including percutaneous needle fasciotomy , fasciotomy (subcutaneous or open), fasciectomy  and dermofasciectomy (DF) .In a companion article  publisheThe study involved a survey of surgeons who perform surgical procedures for DD.Orthopaedic and plastic surgeons from 12 European countries were identified. The countries were selected to take into account geographic variations between middle and northern Europe .A total of 687 surgeons were interviewed, of whom 579 (84%) were orthopaedic surgeons and 108 (16%) were plastic surgeons (Table Responding surgeons had been in practice for an average (SD) of 15.1 (7.9) years, a figure that did not differ appreciably by specialty. Of the 687 surgeons, 56% practiced only in the hospital. The remaining surgeons had mixed practices; 35% of all surgeons had a mixed practice but practiced at least half the time in the hospital, and 10% had a mixed practice but spent the majority of time in the office. Of plastic surgeons, 47% had a mixed practice, a higher rate than that of orthopaedic (33%) or hand (34%) surgeons.Overall, surgeons estimated they saw an average (SD) of 1,612  patients in consultation in 2008. Each responding surgeon treated an estimated average (SD) of 17.5 (19.7) patients with Dupuytren’s contracture using a surgical procedure in 2008. Orthopaedic surgeons treated an average of 16.4 (18.6) patients; plastic surgeons treated 23.3 (24.3) and hand surgeons treated 20.6 (22.9).In a 12-month period, 255 (37%) of the 687 surgeons performed PNF for patients with DD with finger contracture, 530 (77%) performed fasciotomy, 651 (95%) performed fasciectomy and 276 (40%) performed DF  to 7 (very satisfied), surgeons’ mean (SD) overall level of satisfaction was 5.1 1.3) for PNF, 5.2 (1.2) for fasciotomy, 5.7 (1.0) for fasciectomy and 5.1 (1.1) for DF. Factors influencing surgeon satisfaction are shown in Table  for PNF,On a scale of 1 to 7, surgeons reported their patients’ mean (SD) level of satisfaction as 5.3 (1.2) for PNF, 5.3 (1.1) for fasciotomy, 5.6 (1.0) for fasciectomy and 5.0 (1.1) for DF.Surgeons estimated that 82% of their patients received physical therapy for the hand (including the application of a dynamic splint) following their first PNF procedure and that the mean (SD) duration of physical therapy (including use of dynamic splint) was 5.2 (3.9) weeks. Of the other procedures, 94% of patients receiving fasciotomy had physical therapy for a mean (SD) of 5.3 (3.6) weeks, 97% of patients receiving fasciectomy had therapy for a mean of 6.7 (5.1)  weeks and 99% of patients receiving DF had therapy for a mean of 8.5 (6.4) weeks. The patients of hand surgeons were slightly less likely to receive physical therapy after PNF or fasciotomy compared with patients of nonhand surgeons . The proportion of patients receiving physical therapy after fasciectomy or DF was similar for hand and nonhand surgeons.Most surgeons recommended that patients spend some time away from work following their surgery. The mean (SD) time surgeons recommended patients spend out of work was 2.9 (2.5) weeks following the first PNF procedure, 4.6 (2.7) weeks following fasciotomy, 5.5 (2.7) weeks following fasciectomy and 6.3 (3.2) weeks following DF. Orthopaedic surgeons recommended slightly more time out of work following each procedure type than plastic surgeons, and nonhand surgeons recommended slightly more time off than hand surgeons. Also, surgeons recommended approximately 1 week more time out of work following a reintervention procedure .When asked to estimate the percentage of patients who experienced recurrence of flexion in the finger that was operated, surgeons reported higher rates of recurrence and shorter time to recurrence for less aggressive procedures compared with more aggressive procedures Fig. . The meaTo our knowledge, this is the only survey to date that collected, quantified and described the experiences of a large number of surgeons in the management of DD in Europe. The diverse training  and varied practice settings  of surgeons who participated in this study reflects a broad range of disease severity and procedures performed for DD in Europe.In this study across Europe, fasciectomy was the surgeons’ procedure of choice for Dupuytren’s contracture, especially for patients with more advanced disease and when a more effective treatment with less likelihood of recurrence was desired. This finding is similar to that reported in the literature , 6. SurgSurgeons responding to this survey believed their patients who received fasciectomy and DF had lower recurrence rates and longer time to recurrence compared with patients receiving less invasive procedures, a finding that is not surprising. The rate of recurrence after fasciectomy estimated by surgeons in this study 20%) is lower than that reported in the literature (39%) . This ma0% is lowIn some countries fasciectomy, with and without local flaps and Z-plasty, is the dominant procedure for DD. Frequency of different procedures by country may depend on the Tubiana stage of DD most commonly seen in and the surgical traditions of that country. Differences by country in the data collected for this study will be presented in a later publication.The findings of this study demonstrate that patient factors play a role in the type of surgery recommended by surgeons. Surgeons prefer less invasive procedures for older patients and those with more comorbidities Table . SurgeonIt has been demonstrated that hand therapy after surgery results in significant improvement in total digital extension . In thisThe findings regarding time in physical therapy and time out of work illustrate both the direct  and indirect (time out of work) costs associated with the treatment of DD. Indirect costs, including time out of work, have been found to constitute the majority of the total costs of treatment for DD and other hand injuries , 10. In The findings of this study will provide a valuable point of reference when new treatment strategies for DD are introduced. For example, surgeons’ preference to use less invasive techniques in older patients may be related to a higher acceptability of the risk of recurrence in these patients when weighed against patient burden and time to recovery. These concerns may become less salient if new treatments result in reduced patient burden and shortened time to recovery. The findings of this study may also inform decisions regarding the distribution of additional research resources to the treatment of DD.ESM 1(PDF 292 kb)Below is the link to the electronic supplementary material.


The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period.The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients’ records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling . Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people.In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p = 0.044). Ruptured aneurysms were clipped more frequently ; in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR = 2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012.Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period. The dilemma concerning the appropriate treatment of intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. The introduction of Guglielmi detachable coils in 1991 , 11, 14.The excellent and sophisticated scientific descriptions and trend analysis in the treatment of IAs predominantly come from U.S. data and at the same time there is a lack of similar reports from other regions.In this study, the authors present 4-year trends in the treatment of IAs in Poland. Data includes endovascular and neurosurgical interventions, ruptured and unruptured IAs and takes into account the differences between 16 administrative regions of Poland.The present statistical analysis refers to IAs treated in Poland between 2009 and 2012. These procedures are grouped according to the system of diagnosis-related groups (DRG) , as proposed by the National Health Fund . Data were obtained from the NFZ database and supplemented by the official correspondence with the NFZ.Patients’ records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with procedure codes for aneurysmal clipping (39.51) and coiling . Additionally, all aneurysms were subgrouped into either the anterior or posterior cerebral circulation location. In the first stage, the absolute numbers of procedures were estimated, followed by the comparison of results between unruptured vs. ruptured, clipped vs. coiled and posterior vs. anterior cerebral circulation aneurysms. Demographic characteristic for the Polish population and differences in the number of procedures between 16 administrative regions (voivodships) were standardized per 100,000 people. The population data was obtained from Statistical Yearbooks of the Central Statistical Office. The two main cohorts (unruptured and ruptured aneurysms) were compared against one another for two primary end points—in-hospital death and hospital length of stay (LOS). Secondarily, similar comparison in the main cohorts for three other features, unruptured vs. ruptured, clipped vs. coiled and posterior vs. anterior cerebral circulation aneurysms, were conducted. Patients with both a ruptured and unruptured aneurysm in one hospitalization were included in the ruptured group. We excluded patients who were listed with procedure codes for both clipping and coiling, and those who received diagnosis codes for both an unruptured aneurysm and SAH.Multivariable logistic regression was used to calculate the odd ratios and 95 % CIs for the comparison of endovascular treatment and surgical clipping for the in-hospital mortality, sex, length of stay and the anatomical origin of the aneurysms. We also calculated and tabulated category-level compound annual growth rates (CAGRs) for the whole analyzed period. Trends over time were modeled using simple linear regression and tested for significance with analysis of variance (ANOVA), assuming that the dependent variables are numbers of procedures and time points (years) are independent variables. Statistical significance was defined as a type I error <0.05.From 2009 to 2012, 11,051 procedures associated with the treatment of IAs were identified, including 5,968 ruptured and 5,083 unruptured aneurysms.The mean age was 52.3 ± 3.8 years and there were 6,666 women (60.3 %). Five thousand one hundred and twenty-five (46.4 %) aneurysms were treated by neurosurgical clipping and 5,926 (53.6 %) by endovascular procedures. The overall in-hospital mortality rate was 7.1 % and the mean length of stay 9.3 ± 0.9 days. The location ratio of anterior to posterior circulation aneurysms was 6:1 ; the highest number of IAs was in the ICA 3,769 (34 %) and ACA 3,199 (29 %) territory   with CAGR of 10 %. In three other regions the index  was above the average for Poland   in 2002 . There wThe legitimate factors related to the shift in treatment selection include subsequent technologic advances such as more prevalent usage of stent-assistant coiling, increased availability of endovascular procedures. There have also been substantial improvements in endovascular technology, such as bioactive coils, expandable coils, and complex-shaped coils during the same period, which may account for some of observed increase in utilization , 16.Piotin et al. concluded that stent-assisted coiling reduced the recurrence rate, but in exchange, a higher rate of morbidity and mortality has appeared. The overall rate of permanent, procedure-related morbidity and mortality was 12 % for the stent-treated cohort compared with 5 % in the non-stent-treated group .Based on the data from this study, clipping was three times more often utilized than coiling for treatment of MCA IAs. There is a disparity across Europe in the treatment selection for MCA IAs. Northern European countries strongly favour coiling in comparison with the rest of Europe, where clipping is the treatment of choice . The ratThis study showed that the annual in-hospital mortality was 1.2 times higher in the clipping group 7.6 %) compared to endovascular treatment (6.7 %). Endovascular coiling was associated with slightly lower in-hospital mortality for patients with unruptured factors, but higher in SAH group in comparison to clipping. Including all studied IAs, surgical clipping had two times longer mean length of hospitalization than the endovascular treatment (11.9 ± 0.7 vs. 6.6 ± 0.8 days). Similar finding was noted in unruptured group (OR = 2.013), whereas after SAH LOS was almost equal in both methods of treatment. Data from the Nationwide Inpatient Sample showed that in-hospital mortality decreased from 9.7 % to 6.9 % in the clipped group and from 7.2 % to 6.7 % in the endovascular group over a decade (1993-2003)  % compar. The lonHowever, early after endovascular therapy had been introduced, it was used mainly in older patients, poor grade subarachnoid hemorrhage, and large or giant aneurysms. Although the proportions have recently changed toward being more balanced, a slight skew to shift more severe cases to coiling still exists .There is a high disparity across the geographical regions in Poland in the number of procedures. This is consistent with a previous study referring to the overall number of neurosurgical procedures, in which a significant regional scatter of neurosurgical operations was found . RegionaThe trend analysis revealed an increase in overall number of aneurysms treated between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period. Middle cerebral artery aneurysms were predominantly allocated to surgical clipping, whereas posterior circulation aneurysms were mostly treated by endovascular therapy in both unruptured and ruptured groups. The length of hospital stay was almost equal after SAH, but in unruptured aneurysms the hospital stay was two times longer after clipping.A high disparity in the number of procedures across the geographical regions in Poland was pronounced; the difference was especially noticeable in endovascular therapy.


Accurate and reproducible assessments of right ventricular (RV) size and function are important for clinical decisions. RV volume assessment by CMR has been traditionally performed using a short axis orientation (SAX). This projection, however, renders en-face views of the mitral and tricuspid valves. Distinction between atriums and ventricles can be difficult, which can complicate contour tracings for ventricular function. To improve reproducibility, alternative orientations for RV assessment have been proposed. This investigation sought to compare right horizontal long axis (RHLA) and SAX reproducibility in a pediatric cohort.The RHLA method is an oblique-transverse cine stack where the planes are oriented parallel to the diaphragmatic aspect of the right ventricle Figure . We perfMean EDV among the 4 readers was 209.1 ± 65.4 ml by RHLA and 199.2 ± 62.0 by SAX . Mean ESV was 105.8 ± 45.5 ml by RHLA and 101.1 ± 46.3 by SAX . There was no significant difference between individual readers, however measurements by the least experienced person tended to be smaller than the others. RHLA EDV and ESV volumes tended to be 4-5% larger than those measured by SAX, even when factoring only the experienced readers. Mean ejection fractions by RHLA and by SAX were 49.2% and 48.9% respectively. Inter-rater reliability was high, and is reported in Table Both RHLA and SAX measurements result in high inter- and intra- rater reproducibilities, with no clearly-defined advantage between the two approaches. RHLA EDV and ESV volumes tend to be 4-5% larger than those measured by SAX. These differences should be considered when applied to clinical decision-making.None.


Cobb strain) of a day-old age. The chicks were randomly divided into six groups consisting of 15 in each group. Group 1 was maintained as basal diet control and group 2 was kept on lead at 300 ppm in feed throughout 5 wk as toxic control without any treatment. Groups 3 and 4 were maintained on herbal methionine at 1.4 g/kg feed + Mangifera Indica at 0.1% in feed, respectively. Groups 5 and 6 were treated with lead + herbal methionine and lead + M. indica, respectively, for the 5 wk. The concentration of thiobarbituric acid reactive substances (TBARS) and protein carbonyls, and the activities of superoxide dismutase (SOD) and catalase in liver and kidney revealed a significant (P<0.05) increase, while there was a significant (P<0.05) decrease in the concentration of reduced glutathione (GSH) in liver and kidney, and hepatocytic membrane ATPases and cytochrome P450 (CYP450) in liver in the lead toxic control group. Treatment with herbal remedies in groups 5 and 6 resulted in a marked improvement in all the above parameters as compared to those of lead toxic control. Thus, it is concluded that lead induces biological damage by means of oxidative stress and the herbs in test offered better amelioration. The beneficial effects of herbal methionine and Ma. indica may be attributed to their antioxidant, anti-stress and hepatoprotective principles.Lead toxicity was studied in male broiler chicks ( Mangifera Indica against experimental lead toxicosis in broilers.Lead is one of the widely dispersed toxic substances, and sources of lead in environment include lead paints, automobiles, industrial lead emission and lead in food/feed and water. However, lead gasoline combustion in vehicles has accounted for as much as 90% of the total anthropogenic sources of environmental lead. Such accCobb strain) of day-old age were randomly divided into six groups consisting of 15 in each group. The chicks were provided with feed and water ad libitum throughout the experiment. The groups were maintained as per the following feeding schedule for 5 wk in order to study the antioxidant role of herbal methionine  and M. indica against lead-induced oxidative damage.A total of 90 sexed male broiler chicks Group 3: Herbal methionine control M. indica control (0.1% in feed)Group 4: Group 5: Lead + herbal methionineM. indicaGroup 6: Lead + th week and tissues were collected for the assay of reduced glutathione (GSH), in liver and kidney of basal diet control group 1) was 2.37±0.13 and 1.90±0.12, respectively, which was significantly ( was 2.37P<0.05) decreased in lead toxic control group 2 at the end of 5th week. Groups 5 and 6 that were supplemented with herbs revealed significantly (P<0.05) increased activity of SOD as compared to that of lead control. The activity of catalase (μg of H2O2 decomposed/mg protein/min) in liver and kidney of basal diet control (group 1) was 11.65±0.58 and 10.50±0.34, respectively, which was significantly (P<0.05) decreased in lead toxic control group 2 at the end of 5th week. Groups 5 and 6 that were supplemented with herbs revealed significantly (P<0.05) increased activity of catalase as compared to lead control [Tables The activity of SOD (U/mg protein) in liver and kidney in basal diet control group 1) was 13.36±0.57 and 9.02±0.47, respectively, which was significantly  and intracellular free Ca2+, and consequently, down-regulated CD95L mRNA expression and CD95-mediated activation-induced cell death (AICD). Mu. pruriens has the ability to scavenge DPPH  radicals, ABTS radicals and reactive oxygen species. It significantly inhibits the lipid oxidation[2’−).[Mu. pruriens decreased the levels of lipid peroxidation and increased the levels of glutathione (GSH), superoxide dismutase (SOD) and catalase (CAT).[The concentration of TBARS and protein carbonyls in liver and kidney was significantly increased in toxic control group, while the activities of SOD and catalase, and the concentration of GSH in liver and kidney were reduced, suggesting the ongoing peroxidative stress and compromised antioxidant defense mechanisms. Enhanced oxidative stress contributes to lead-induced toxicity, where restoration of a cells’ antioxidant capacity appears to provide a partial remedy. Several studies are underway to determine the effect of antioxidant supplementation following lead exposure. Data suggest that antioxidants may play an important role in abating some hazards of lead. It has b11 pruriens and A. c[A. cepa, besides otential. The aqueez et al, reportedoxidation and effeion[2’−). Treatmense (CAT).+/K+ ATPase and Mg2+ ATPase (μM of Pi released/mg protein/30 min) in liver of basal diet control group 1 was 6.81±0.50 and 13.53±0.59, respectively, which was significantly (P<0.05) decreased in lead toxic control group 2 at the end of 5th week. Groups 5 and 6 that were supplemented with herbs revealed significantly (P<0.05) increased activity of ATPases as compared to lead control. The activity in groups 3 and 4 was comparable to that of basal diet control. The activity of CYP450  in liver of basal diet control group 1 was 0.09±0.01, which was significantly (P<0.05) decreased in lead toxic control group 2 at the end of 5th week. Groups 5 and 6 that were supplemented with herbs revealed significantly (P<0.05) increased activity of CYP450 as compared to lead control. The activity in groups 3 and 4 was comparable to that of basal diet control [The activity of Na control .+/K+ ATPase, Mg2+ ATPase and CYP450 were significantly reduced in the liver of lead toxic control. Lipid peroxidation is a natural and deleterious process. The decrease in the levels of Na+/K+ ATPase, Mg2+ ATPase and CYP450 could be due to enhanced lipid peroxidation by free radicals in lead treated groups. Since these membrane-bound enzymes are sulfhydryl (SH) group containing and are lipid-dependent, any alteration in the membrane lipids owing to lipid peroxidation may significantly alter their activity. The treated groups revealed slight improvement in the membrane bound enzymes though the activities were not exactly similar to those of controls. It has been reported that dietary lead alters fatty acid composition and membrane peroxidation in chick liver microsomes.[The activities of Nacrosomes. These fiMa. indica could significantly reverse the oxidative stress induced by lead. The beneficial actions of herbal methionine and Ma. indica may be attributed to their antioxidant, anti-stress and hepatoprotective principles.The results of the present study enunciated that supplementation of herbal methionine and


The febrile response in the context of infection may be linked to a protective host response through enhanced immune function at elevated body temperatures -9. AlterTo determine whether fever is associated with reduced risk of death in patients admitted to an ICU with infection compared with other patients.A retrospective cohort study using a database of Australian and New Zealand (ANZ) ICU admissions as a development cohort and a database of UK ICU admissions as a validation cohort. The sample included 129 ICUs in ANZ and 201 ICUs in the UK. The ANZ development cohort consisted of 269,078 patients and the UK validation cohort consisted of 366,973 patients. All patients were admitted to an ICU between 2005 and 2009. A total of 29,083/269,078 (10.8%) ANZ patients and 103,191/366,973 (28.1%) UK patients were categorised as having an infection at the time of ICU admission. The main outcome measures were the association between peak temperature in the first 24 hours after ICU admission and in-hospital mortality in patients admitted with or without infection.In the ANZ cohort, adjusted in-hospital mortality risk progressively decreased with increasing peak temperature in patients with infection. Relative to 36.5 to 36.9°C, the lowest risk was at 39 to 39.4°C . In patients without infection, the adjusted mortality risk progressively increased above 39.0°C . In the UK cohort, findings were similar with adjusted odds ratios at corresponding temperatures of 0.77 (95% CI = 0.71 to 0.85) and 1.94 (95% CI = 1.60 to 2.34) for the infection and non-infection groups, respectively. See Figures Peak temperature in the first 24 hours in the ICU is associated with decreased in-hospital mortality in critically ill patients with an infection; randomised trials are needed to compare the effect on mortality of controlling fever against a permissive approach to fever management in such patients.


It is a known fact that the surgery of the anterior leaflet presents more difficulties and more dubious results than in the posterior leaflet. The use of artificial chordae is not always effective and measure its length is a challenge for the surgeon. So we present our long-term results with our new original technique for shortening the elongated chordae we call,” twisting loop technique “(TLT).This technique is made by twisting each prolapsed chord, near the edge of the corresponding leaflet, making a loop and tying it to the edge of the leaflet .We analize results in 20 patients .14 were men and 6 women. Mean age was 66+/- 9 years EF =0.55+/-0.10 NYHA CLASS= 2.5+/- 0.7. Mitral regurgitation was severe in all patients This method was applied to 34 elongated chordeae (28 in anterior leaflet and concomitantly in other 6 in posterior leaflet) Etiology was degenerative in all cases Concomitant surgery was: Eight quadrangular resection in P2, Three cleft closure, two A2 plicatures, three aortic prosthesis and three tricuspid rings .In all cases mitral ring was implanted. Mean cross- clamp time was 92+/-21 minutes.There was no surgical mortality. Twenty valves where competent at hospital discharge. Mean follow up is 33+/-14 months (range 54-12) Mean postoperative NYHA CLASS was 1.22+/-04 In echocardiographic evolution ,one year later, 19 patients presented mitral competent valves (95%) One case had mild echocardiographic regurgitation. EF =0.56 +/-0.10. Ventricular diastolic diameters decreased from 60+/-9 to 50.5+/-5 millimeters ((p<0.01). . All patients are in good clinical situation.Our “twisting loop technique” (TLT) for anterior leaflet demonstrated very good results initially and in long term follow up. Simplicity of this technique is useful to correct mitral prolapsed valves and is our preferred option for these patients. These results must be confirmed with longer follow up studies.


Purpose. Subjective tinnitus has different forms and degrees of severity. Many studies in the literature have assessed psychoacoustic characteristics of tinnitus but hardly any of them had focused on the association of audiological profile with onset duration and loudness perception. The aim of this study was to evaluate existence of any association between tinnitus loudness/onset duration and audiological profile to explain differences in prognosis. Method. Study design was prospective. The sample consisted of 26 subjects having tinnitus, which was divided into tinnitus and nontinnitus ears. Audiological profile included pure-tone audiometry, speech audiometry, tympanometry, acoustic reflex test, and auditory evoked potentials (early and middle latency). Unpaired t-test was applied to compare two subgroups. Correlation and association between tinnitus onset duration/loudness perception and audiological profile were also assessed by calculating Spearman's coefficient and Fischer exact value. Results. The two subgroups had significant differences for pure-tone and speech audiometry hearing thresholds. A significant association was observed between the high frequency/extended high frequency and tinnitus loudness/onset duration. Conclusion. The changes in hearing thresholds and auditory pathway are associated with an increase in tinnitus loudness and its onset duration. This knowledge would be helpful to differentiate between severity and chronicity of the patients for planning therapeutic management and predicting prognosis. Subjective tinnitus is the perception of sounds by the patient without any physical presence of acoustic stimulus . The perSubjective ratings of tinnitus loudness, using visual analogue scales, have been found to correlate with distress , althougMany aspects of tinnitus are yet to be answered completely as what are the differences in tinnitus ear and nontinnitus ear; how the loudness perceived is relevant to treatment; whether it is associated with auditory changes; whether the onset was recent or long standing; and how these differences affect the prognosis of tinnitus. It was observed in our tinnitus therapy clinics that these differences seemed to play some role in prognosis and this information might help in planning focused and effective management of the subjects with tinnitus. Therefore the objective of the present study was to find any possible correlation of the perceived loudness and onset duration of tinnitus with audiological profile and its role in treatment. The null hypothesis was made of no correlation between the variables and had no impact on treatment plan.This was a nonrandomized study which included 30 subjects who were seeking treatment for their tinnitus problem in outdoor patient services of the institute. A prior approval of the institute ethics committee was obtained before commencement of the study. Due to the time constraints of the study, a small sample was selected and consisted of subjects of either sex from rural and urban backgrounds. There was a dropout of 4 subjects; hence analysis was done with 26 subjects. All the subjects had chief complaint of idiopathic subjective tinnitus with or without hearing loss. The inclusion criteria were healthy external or middle ear on clinical examination, consistent tinnitus of more than 10-week duration, and those who gave their written consent for the study. Patients with external or middle ear pathology, suspected Meniere's disease or otosclerosis, history of ototoxicity, sudden hearing loss, or ear trauma or having any systemic disorders were excluded.The cases were subjected to a complete clinical and audiological assessment. The audiological assessment consisted of pure-tone audiometry , high frequency audiometry (HFA), extended high frequency audiometry (EHA), speech audiometry (speech reception threshold (SRT), speech discrimination score (SDS), most comfortable level (MCL), and uncomfortable level (UCL)), Tympanometry, acoustic reflex testing (ART) , auditory brainstem responses (ABR), middle latency responses (MLR), tinnitus matching (pitch and loudness), and residual inhibition (RI). Otoacoustic emission (OAEs) and magnetic resonance imaging (MRI) were done in few selected cases. The different equipment used for the audiological investigations included Madsen orbiter 922 clinical audiometer, Siemens SD 30 tympanometer, evoked potential system developed by Intelligent Hearing System, USA, and otoacoustic system developed by Intelligence Hearing System, USA. The assessment also included subjective scaling  of annoyance and sleep disturbance due to tinnitus. These investigations were done in two visits of 50–60 minutes each prior to start of treatment. The management was planned as combination of masking therapy, environment enrichment with music, and cognitive behavior therapy.Statistical Analysis. The data was subjected to the values of mean and median for central tendency and standard deviation (SD) for variability. Unpaired t-test was applied for comparison of tinnitus and nontinnitus ears. Spearman's correlation coefficient (rho) was calculated between psychoacoustic characteristics and the audiological profile of tinnitus ears. Fischer's exact test was used as a nonparametric inferential test to verify any association between tinnitus onset duration and type of hearing loss. Similarly it was also used to verify any association of tinnitus loudness with the type of hearing loss. All significance tests were two tailed and conducted at or above the 95% significance level (P < 0.05).The 26 subjects included in the study ranged from 16 to 45 years of age with a mean 37.12 years ± SD of 8.57. Males and females were equally distributed. The psychoacoustic characteristics included tinnitus ear, duration of tinnitus since onset, pitch matching, loudness matching, and residual inhibition of tinnitus. 28% of the subjects had tinnitus in the right ear, 40% had in the left ear, and 32% had tinnitus perception binaurally. The sample was divided into two groups, tinnitus ears (35 ears) and nontinnitus ears (17 ears).The majority of tinnitus ears (72%) had onset duration longer than six months. 22.9% of the ears had duration of tinnitus perception <0.5 yrs (2.5 months–6 months), 25.7% of the ears had tinnitus perception since 0.5 to 1 year, 2.9% since 1.0 to 1.5 years, 14.3% since 1.5 to 2 years, 17.1% since 2.0 to 5.0 years, and 17.1% since >5 years. Tinnitus matching was done where 44% of the ears had pitch perception <6000 Hz and 48% had perception ≥6000 Hz. Loudness matching showed that 24% of the subjects had faint tinnitus perception ≤30 dB HL, 44% had loud (31 to 50 dB HL), 20% had too loud (51 to 70 dB HL), and 12% had extremely loud level (71 to 90 dB HL). Loudness matching was done contralaterally in hearing level (HL) units rather than in sensation level units (SL) . ResiduaThe level of annoyance was subjectively reported by the individuals on a 5-point scale, where 0 = no annoyance, 1 = little annoyance, 2 = average annoyance, 3 = high annoyance, and 4 = intolerable. All of the subjects reported level of annoyance as average or more than average, that is, ≥2. The sleep disturbance due to tinnitus was rated on a 5-point scale as 0 = never affected, 1 = rarely affected, 2 = sometimes affected, 3 = mostly affected, and 4 = always affected. Out of the total 26 subjects, 22 reported sleep disturbance as sometimes affected due to tinnitus, two of the patients reported as mostly affected (since <6 weeks), and one reported as always affected (since 2 weeks).Based on pure-tone audiometric thresholds, PTA1  was calculated for both right and left ears , and hearing status of the subjects was categorized into mild, moderate, moderate to severe, severe, and profound  . SimilarThe data shows that 60% (21 ears) of tinnitus ears had normal hearing on conventional audiometry (PTA1), 20% (7) ears had mild hearing loss, 11.4% (4) had moderate hearing loss, and 8.6% (3) of tinnitus ears had severe hearing loss. None of the tinnitus ears had profound hearing loss . The datOn high frequency audiometry (PTA2), 34.3% (12 ears) of the tinnitus ears had normal hearing, 17.1% (6 ears) had mild hearing loss, 14.3% (5) ears had moderate hearing loss, 17.1% (6) ears had moderate to severe hearing loss, 11.4% (4) ears had severe hearing loss, and 5.7% (2) of the tinnitus ears had profound hearing loss . For nonAccording to extended high frequency audiometry (PTA3), 5.7% (2 ears) of the tinnitus ears had normal hearing, 20% (7) ears had mild hearing loss, 17.1% (6) ears had moderate hearing loss, 28.6% (10) ears had moderate to severe hearing loss, 17.1% (6) ears had severe hearing loss, and 11.4% (4) of the tinnitus ears had profound hearing loss. For nontinnitus ears on PTA3, 23.5% (4) had normal hearing, 35.5% (6) ears had mild hearing loss, 17.6% (3) ears had moderate hearing loss, 17.6% (3) ears had moderate to severe hearing loss, and 5.8% (1) ear had profound hearing loss . The speech reception threshold (SRT) was normal, that is, ≤25 dBHL in 57.1% (20 ears) of the tinnitus ears, and 17.1% (6) of the tinnitus ears had SRT between 26 and 40 dBHL. It shows that the majority (74.2%) of tinnitus ears had good speech reception at general conversational levels . Speech The SRT was normal, that is, ≤25 dBHL in 82.3% (14ears) of the nontinnitus ears, and the rest 17.64% (3) of the ears had SRT between 26 and 40 dBHL . Speech The interpeak latency (IPL) of wave I-III was considered normal as 1.6–2.4 ms, shortened as <1.6 ms, and prolonged as >2.4 ms. Wave III-V IPL was normal as 1.8–2.2 ms, shortened as <1.8 ms, and prolonged as >2.2 ms. The IPL of wave I–V was normal as 3.6–4.4 ms, shortened as <3.6 ms, and prolonged as >4.4 ms. The correction (0.1 ms for every 10 dB of hearing loss above 50 dB) was applied to calculate the absolute latency of wave V when the subject had hearing loss greater than 50 dBHL at 4000 Hz .The IPL of wave I–III was observed as normal in 82.8% (29 ears) of the tinnitus ears, prolonged in 8.6% (3) ears, and no response in 8.6% (3) ears. None of the ears had shortened wave I–III interpeak latency. In non-tinnitus interpeak latency of wave I–III was normal in 94.1% of the ears (16 ears), and prolonged in 5.9% (1) of the ears. None of the ears had shortened IPL of wave I–III. Wave III–V interpeak latency was normal in 17 tinnitus ears (48.6%), shortened in 16 ears (45.7%), and prolonged in one tinnitus ear (2.8%) and there was no response in one ear (2.8%). In non-tinnitus ears wave III–V was observed as normal in 10 ears (58.8%) and shortened in seven ears (41.2%). Data shows IPL of wave I–V as normal in 30 tinnitus ears (85.7%), shortened in one ear (2.8%), prolonged in one ear (2.8%), and no response in three ears (8.6%). IPL of wave I–V in non-tinnitus was normal in 88.2% (15) of the ears, shortened in 5.9% (1), ears and prolonged in 5.9% (1) of the ears. MRI was normal in this one subject. Magnetic resonance imaging (MRI) was recommended in subjects with unexplained prolonged IPL of waves to ensure no retrocochlear pathology. Those with retrocochlear pathology were excluded from the study.μV and abnormal as <0.50 μV.Peaks observed during MLR were Na, Pa and Nb waves, out of these amplitude of waves Na and Pa were analyzed. The amplitude of waves Na and Pa was considered normal as ≥0.50 Wave Na had normal amplitude in 94.3% (33 ears) of the tinnitus ears, abnormally low in 2.8% (1) of the ears, and no response in 2.8% (1) of the tinnitus ears. Amplitude of wave Pa was normal in 32 ears (91.4%), abnormal in 2 ears (5.7%), and of no response in 1 tinnitus ear (2.8%). In non-tinnitus the amplitude of waves Na and Pa was observed to be as normal in all of the 17 ears (100%).t”-test. The comparison was made between all the measured audiological parameters, but the results of statistically significant findings are depicted in the tables. The two groups tinnitus and non-tinnitus ears were compared with unpaired “Positive correlation was observed between tinnitus onset duration and high frequency thresholds . Similarly positive correlation was also observed for extended high frequency threshold (12000 and 14000 and EHF average PTA3). Positive correlation was also observed between tinnitus duration and absolute latencies of waves III and V of ABR .Negative correlation was observed between duration and speech discrimination score (SDS) in tinnitus ears. None of the correlation coefficient values was statistically significant between tinnitus duration and interpeak latencies of ABR waves. Similarly, none of the correlation coefficient values was statistically significant between duration and amplitude of middle latency evoked response (MLR) waves Na and Pa.Significant correlation was observed between perceived tinnitus loudness and conventional audiometric thresholds and average. Similarly significant correlation was found for high frequency and extended high frequency thresholds. As shown in f = 21.149, P < 0.05) was found between duration and conventional hearing loss (PTA1). Similarly significant value  between duration and high frequency hearing loss (PTA2) was observed. Association of duration with extended high frequency hearing loss (PTA3) (f = 24.25) was nonsignificant.Fischer's exact test was used to evaluate the association between tinnitus onset duration and type of hearing loss. Statistically significant association value . Association was also statistically significant  between tinnitus loudness and high frequency hearing loss. It was nonsignificant for extended high frequency hearing loss (f = 18.507).Fischer's exact test was also used to assess association of perceived tinnitus loudness with type of hearing loss. Association was significant between loudness and conventional hearing loss (PTA1)  and individual cognitive behavior therapy (CBT) was given for two weeks. Improvement was defined objectively as change in loudness level ≥15 dBHL plus subjectively as improvement on a 5-point scale of annoyance rating and a 5-point scale of sleep disturbance. When the loudness level was faint or loud and onset duration was <0.5 years, the prognosis reported by the subjects was good immediately after completing therapy and six months later. Given similar management the subjects with loudness perception of 51 dB HL to 70 db HL (too loud) and/or onset duration 0.5–1 year reported fair improvement immediately after the therapy and some relapse by 2-3 months hence needed further therapeutic management. When onset duration of tinnitus was longer than 2 years and/or loudness was 71−90 dbHL (extremely loud) with this therapeutic plan, there was hardly any improvement and the subjects were shifted to other management strategies after 2 weeks like combination with electrical stimulation.In the study, the majority (60% of tinnitus ears and 80% of non-tinnitus ears) of the subjects had normal hearing on conventional pure-tone average (PTA1) which goes in accordance with the results published by Roberts et al. . Other sHearing thresholds were poorer in high frequency region 4000, 8000, and 12000 Hz. Roberts et al.  also repMost of the tinnitus subjects in our study had hearing loss in both ears by extended high frequency (EHF) average (94.2% of tinnitus ears and 76.5% of non-tinnitus ears). However, on comparison of tinnitus and non-tinnitus ears, significant differences were observed for extended high frequency hearing thresholds and PTA3. Barnea et al.  found thABR studies in the literature do not reveal any shortening of IPL I–III, III–V, or I–V waves. However, we found wave III–V interpeak latency shortening (<1.8 msec) in many subjects (45.7% in tinnitus ears and 41.2% in non-tinnitus ears). This indicates lesser conduction time of auditory stimulus at higher brainstem level. Moller  studied It therefore becomes clear that tinnitus perception is associated with changes in auditory pathway especially the areas responsible for high frequencies and extended high frequencies processing. And these changes are correlated with prolongation of time and increase in intensity of tinnitus perception.According to psychological models, promising treatment for tinnitus is to modify the central nervous substrate of tinnitus and consequently its percept . Tyler  reportedThis study has some limitations which could be addressed in future studies. Though a thorough case history of the subjects was taken, the possibility of pretinnitus hearing loss or audiological problems cannot be fully ruled out. Inclusion of radiological investigations particularly functional MRI would have been beneficial and would have added to the validity of the changes. The bigger sample would be safe to generalize the findings.The duration and/or loudness of tinnitus perception has strong association with changes of auditory system. There might be progressive changes on hearing and auditory pathway due to longer onset duration/tinnitus loudness or vice versa. This information should be collected during assessment to be used for planning management in a focused and effective manner. It might also be used for predicting prognosis.


Surgical patients are submitted to numerous factors that may cause postoperative hypothermia, such as a cool operating room environment, cold intravenous fluids and blood, cold antiseptic skin preparations and anesthetic-induced impairment of thermoregulatory control. Hypothermia may increase susceptibility to surgical wound infection, length of stay, intraoperative blood loss, morbid cardiac events, postoperative shivering, coagulopathy and also altered duration of drug action. The objective of this study was to evaluate the impact of hypothermia at ICU admission on hospital length of stay and mortality in a surgical ICU.A prospective cohort study conducted on patients admitted to the ICU of Hospital Santa Luzia, Brasilia, Brazil, during the period of 1 year. Hypothermia was defined as axillary temperature inferior to 35.5°C (95.9°F). Patients were divided into groups with hypothermia (HG) and without hypothermia (NG).n = 4), 1.9% (n = 9) and 4.1% (n = 20), respectively. Patients with hypothermia had higher APACHE II score  and SAPS II . There was no difference regarding the age of the groups and the hospital length of stay . However, the group with hypothermia had higher mortality rates . The relative risk for hospital mortality in patients with hypothermia at ICU admission was 4.6 (95% CI: 1.02 to 29.88).A total of 484 patients were enrolled. Mean age was 59 ± 16 years and 52.5% were male. Seventy-eight patients (16.1%) were submitted to emergency surgeries. Mean APACHE II score was 8 ± 5, mean SAPS II was 16 ± 10. Twenty-four patients (5%) had hypothermia at the time of ICU admission. The general mortality rate at 7 days, 28 days and hospital mortality was 0.8% (Few patients were hypothermic at the time of ICU admission in the immediate postoperative period. This may reflect the effectiveness of perioperative warming of the patients. Hypothermia at ICU admission was associated with greater severity scores and increased hospital mortality in this sample of surgical patients studied.


Differences in admission patterns, delivery of care and outcomes between women and men admitted to the ICU have been previously identified . HoweverWe used data from a large retrospectively cohort study in which adults with severe TBI (GCS ≤8) admitted to six Canadian level I trauma centres (2005 to 2006) were identified through health records using ICD-10 codes [P = 0.003). We observed similar findings in patients <55 years old , but not among men and women aged ≥55 years old . Adjusted hazard ratios (HRs) showed a nonsignificantly increased risk of death in women aged <55 years old as compared to men (1.51 (0.92 to 2.47)), and in women aged ≥55 years old (1.53 (0.94 to 2.50)). We observed no difference both in the overall unadjusted incidence of WLST between women and men  and in women and men aged <55 years old, while there was a nonsignificantly increased rate of WLST in women ≥55 years old (HR 1.53 (0.94 to 2.50)).Among 720 patients, 165 were women (22.9%), 506 (70.3%) aged <55 years old and 214 (29.7%) ≥55 years old. Overall mortality was 31.7% and 70.2% of deaths occurring following the WLST [There may be gender-based differences in outcome among patients with severe TBI. Overall, mortality for women tended to be higher, as were decisions for WLST. These differences may be due to unmeasured confounders, biologic responses to TBI, or differences in level of care decision-making.


Objective: To see the various clinical presentations and biochemical profile in adult celiac disease patients of Hyderabad Sindh.Methods: A total 60 suspected cases of adult celiac disease, both males and females were screened out from Liaquat University of Medical and Health Sciences hospital and private clinics at Sadar Hyderabad Sind by non probability purposive sampling during a period from July 2011 to December 2012.Age ranged between 18 to 55 Years. A detailed history and clinical examination was done. Patients already on gluten free diet, age <12years, tuberculosis or cancer of intestine/colon and patients of diabetes and thyroid disorder were excluded, while patients having positive ant tTG  were included. The biochemical profile including serum albumin, calcium ,ferritin, SGPT, Alkaline phosphatase and Haemoglobin were estimated in central Diagnostic laboratory LUMHS by taking 10 cc centrifuged blood sample. The data was plotted on SPSS 16, mean and percentages were calculated. Results: All patients were divided in to three groups according to age. The most common group was 18-30 years;  comprised 56.6%. The commonest clinical presentation was diarrhoea in 50%, menstrual irregularity in 21%, walking problems 21%, undue fatigue in 15% and edema in 15%. P values calculated in quantitative variable of males and females. The p value was significant in between serum calcium (p 0.004), haemoglobin , serum ferritin (<0.005) and alkaline phosphatise (<0.005).Conclusion: This study showed that Adult celiac disease was present with entirely different clinical and biochemical profile in patients in this region. In older children and adults, symptoms are often nonspecific, such as abdominal pain, anemia, osteoporosis, fatigue, and even depression. Consequently, the diagnosis may easily be delayed or even missed.3 The etiology of CD is complex, where both genetic and environmental factors are involved. The human leukocyte antigen (HLA) genes encoding class II molecules i.e. DQ2 and DQ8 are risk factors. More than 90% of patients expressed DQ2 molecule while remaining carried DQ8 molecule.Celiac disease (CD) is gluten – induced multisystem autoimmune disorder and small intestine is the primary target.4 The disease has been well documented in Asians from India, Pakistan, and Iran.5 Using simple serological tests; it has gradually become clear that the prevalence of CD in different countries in the Middle East, North Africa, and India where wheat has been the major staple food for many centuries is almost the same as that in Western countries. Clinical studies showed that presentation with nonspecific symptoms or no symptoms is as common in the Middle East as it is in Europe. The CD is frequently unrecognized by physicians, in part because of its variable clinical presentation and symptoms.6 The recent reports have been shown that celiac disease is a common disorder in North Africa,7 the Middle East, India8 and Pakistan.9The definitive diagnosis of CD was based on biopsy of small intestine that demonstrated increased number of intestinal lymphocytes, crypt hyperplasia and villous flattening which resolved on gluten – free diet.10 Majority of the patients with atypical symptoms of celiac disease do not report to the hospitals in Pakistan. The “atypical form” of the disease is characterized by few, or no gastrointestinal. Symptoms. It predominantly presents with extra intestinal features such as neurological, Dermatological, hematological, endo crinological, reproductive, renal, psychiatric, skeletal, and liver involvement. Taddeucci et al conducted a study on 26 patients with CD and found that 31% were having abnormalities in central nervous system.11 The antigen against which EMAs are directed is tTG. The anti-tTG antibodies are highly sensitive and specific for the diagnosis of CD.12 Enzyme-linked immune sorbent assay (ELISA) tests for IgA anti-tTG antibodies are now widely available and are easier to perform, less observer-dependent, and less costly than the immunofluorescence assay used to detect IgA EMA antibodies.13A significant number of adult patients with celiac disease remain either silent or asymptomatic. In some reports celiac disease has been recognized as late as 70 years of age.14 They studied new cases of celiac disease diagnosed between 2000 and 2006 prospectively included (66 children and 54 adults). The clinical spectrum was categorized in two groups: (a) typical  and (b) oligosymptomatic . In the real sense worldwide, CD “out of the intestine” is 15 times more frequent than CD “in the intestine making the diagnosis extremely challenging.15 This study aimed to focus the clinical presentation and biochemical changes in adults suffering from celiac disease in Hyderabad. The awareness of celiac disease in this area is very little especially when celiac disease has been presented other than diarrhea.The clinical presentations are different in age groups such as shown by Santiago Vivas MD.Sixty patients suspected cases of adult celiac disease were screened out from Liaquat University of Medical and Health Sciences Hospital Hyderabad / Jamshoro and private clinics at Sadder, Hyderabad, Sindh by non probability purposive sampling, 22 were males (36.6.%) and 38 were females (63.3%).The age ranged between 18 to 55 years. The study was approved by ethical review committee of LUMHS.A written consent was taken from all the patients. A detailed history and clinical examination was done. Patients already on gluten free diet, age <12years, tuberculosis or cancer of intestine/colon and patients of diabetes and thyroid disorder were excluded, while patients having positive ant tTG  were included. All groups had been sub categorized according to symptoms of initial presentation. The male to female differences noted according to biochemical profile. The main presentations were diarrhoea, menstrual irregularities, undue fatigue, walking difficulty and edema of feet. The biochemical profile including serum albumin, calcium ,ferritin, SGPT, Alkaline phosphatase and Haemoglobin were sent to central Diagnostic laboratory LUMHS by collecting 10 cc centrifuged sample. The data was plotted on SPSS 16, mean & percentage was calculated. The difference between male and female means in five biochemical parameters was calculated; serum albumin, calcium, haemoglobin serum ferritin and alkaline phosphatase. Two independent student t test were applied to observe mean difference in qualitative biochemical variables. P value was considered <0.005 significant.nd group, 31-42 Years (28.2%), mean age was 35.5± 3.5 and 3rd group was in between 43-55 years (15%) mean was 47.6±4.2. The most common group was 18-30 years (mean 23.5±5.6) comprised 56.6%  were male and 38 (63.6%) were females. The age range was 18 to 55 years mean age was 38±10.5 years. All patients were categorized in to three groups according to age; group 1, 18-30 (56.6%) years mean age was23.5±5.6, 2ed 56.6% . SPSS veed 56.6% ., serum calcium 8.0±1.8 and 7.9±1.4, p 0.004, haemoglobin 12.3±2.611.8±2.0 p 0.004, serum ferritin 23±10.217±9.45 p <0.005 and alkaline phosphatise 270±65.7 and 280±95.4 <0.005  p value was 0.0064 <0.005 .16 enrolled 1612 patients from all United States and the women predominated (2.9:1). They also shown age of presentation in adult celiac disease could be as late as 5th decade. The majority of respondents were diagnosed in their fourth to sixth decades.This study was conducted in tertiary care hospital of Hyderabad Sindh. Total 60 patients were enrolled with clinical presentation of adult celiac disease in relation of biochemical parameters. In our study the female were dominated and the male to female ratio was 3:1(63 % vs. 22%). This ratio is matched with many national and international studies. Green et al17 et al where they found thirty patients (50/30) were female (60%) and mean age of participants was 33.25+ 9.7 years. Majority of (86%) patients presented with typical gastrointestinal symptoms. In their study they measures four clinical presentations while in our study we have 8 clinical presentations.In our study mean age was 37.8±12.5, out of 66 patients 65% were female and 34% were males and the main presentation was diarrhea in 50%. This ratio was lower than a study conducted in Hyderabad by Sadique, serum calcium 8.0 mg/dl±1.8 and 7.9mg/dl±1.4, p 0.004, haemoglobin 12.3 g/dl±2.611.8±2.0 p 0,004, serum ferritin 23mg/dl±10.217±9.45 p <0.005 and alkaline phosphatase 270iu/l±65.7 and 280iu/l±95.4 <0.005. Lionetti E et al18 demonstrated in their study Unexplained iron-deficiency anemia (3–15%). Green PH et al19 showed unexplained hypertransaminasemia (2–9%), Osteoporosis and osteomalacia of premature onset (2–4%) and recurrent abdominal pain or bloating.20In our study, biochemical parameters are comparable to different studies conducted in different areas of world. We have found the serum albumin was 3.4g/dl ±1.28 and 3.2±1.3 and p value was 0.00621 who has provided evidence to support atypical symptoms was 2.5 times more common than the classically described gastrointestinal presentation. In particular iron deficiency anemia accounted for 20.1% of all cases. They observed less than 5% patients with raised liver enzyme. In our study we have observed raised SGPT in 6 patients (10%). These raised levels in our patients were because they have used different drugs prescribed by general practitioners like analgesics, ATT, antidepressants. In our study the iron deficiency was present in both sexes. The patients commonly presented with undue fatigue in 15%. The serum iron levels were low and the mean value was 4.5mg/ dl. Our study matched with Sanders DS et al22 et al who documented Infertility, reduced fertility, and an increased risk of an adverse outcome during pregnancy  have all been attributed to undiagnosed celiac disease.In our study 21% patients presented with different menstrual irregularities but we didn’t observe any reduction in fertility which is not match able to international studies such as carried out by Lewis23 observed 1.9-16% ataxia of un known origin and alopecia in 2%. In our study walking difficulty was observed in 21% which is slightly higher than Andrew and the alopecia in 13% patients which is quite higher than above study. Our patients were on different medicines along with other nutritional deficiencies so alopecia was quite higher in our study.Andrew et alCeliac disease is presents in many ways. In adults the extra intestinal features are common such as undue fatigue, menstrual irregularities and walking difficulties. This study provides awareness of clinical and biochemical parameters of this important disease.Naila Masood: Critical review and writing the final manuscript. Imran Ali Shaikh: Collection of data, statical analysis and writing of manuscript.


Standard anaesthetic practice in the high-risk surgical patient is to insert invasive arterial and central venous catheters and then to use ΔCVP and ΔMAP to guide fluid therapy, despite an accumulation of evidence to suggest that filling pressures are inadequate predictors of fluid status and responsiveness. Recent interest has been directed towards dynamic measures of cardiac filling such as SVV, SPV, PPV and Δdown and ΔVpeak. A number of large multicentre trials are underway using the LiDCOrapid. There is, however, little information about the utility of this device or, indeed, any other minimally-invasive cardiac output monitor in the prediction of fluid responsiveness.The haemodynamic parameters of 70 high-risk patients  undergoing major vascular surgery (mean duration 4.2 ± 1.1 hours) were evaluated retrospectively using LiDCOviewPro. All patients underwent standard induction and maintenance of anaesthesia, with propofol/remifentanil TIVA and IPPV  via a supraglottic airway. Monitoring included BIS, NICO and LiDCOrapid. Fluids were administered according to clinical assessment of need and available haemodynamic parameters. Only fluid boluses given in the absence of HRV >10%, brisk ongoing blood loss and of volume ≥250 ml were included in the evaluation. Positive response to a fluid challenge was defined as ΔSVI ≥10%. Statistical analysis was performed using SPSS 17.0.P = 0.08), -0.01 and 0.18 (nonsignificant). The AUROCs were 0.75 (95% CI = 0.57 to 0.93), 0.587 (0.36 to 0.82) and 0.67 (0.48 to 0.86), respectively. The best cut-off value for SVV using Youden's index was 13.5%, with J = 0.48. The positive likelihood ratio was 2.74 and the negative likelihood ratio 0.34, with diagnostic odds ratio 8.06 at this level.Thirty-two out of 43 valid fluid challenges were positive (74.4%). The correlation coefficients between the baseline SVV, SPV and PPV with ΔSVI were 0.27 (It has been reported that only 50% of critically unwell patients respond to fluid challenge, compared with 74.4% in this intraoperative study of noncardiac surgical patients. The SVV was an adequate predictor of fluid responsiveness. The diagnostic threshold of 13.5% was consistent with previous studies.


Several studies have shown that, although transplantation of neural stemcells into the contusion model of spinal cord injury (SCI) promoteslocomotor function and improves functional recovery, it induces a painfulresponse, Allodynia. Different studies indicate that bone marrow stromalcells (BMSCs) and Schwann cells (SCs) can improve locomotor recovery whentransplanted into the injured rat spinal cord. Since these cells arecommonly used in cell therapy, we investigated whether co-transplantation ofthese cells leads to the development of Allodynia.In this experimental research, the contusion model of SCI was induced bylaminectomy at the T8-T9 level of the spinal cord in adult female wistarrats (n=40) weighting (250-300g) using the New York UniversityDevice. BMSCs and SCs were cultured and prelabeled with5-bromo-2-deoxyuridine (BrdU) and1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanineperchlorate (DiI) respectively. The rats were divided into five groups of 8including: a control group (laminectomy only), three experimental groups and a sham group. The experimental groupsreceived BMSCs, SCs, and BMSCs and SCs respectively by intraspinal injection7 days after injury and the sham group received serum only. Locomotion wasassessed using Basso, Beattie and Bresnahan (BBB) test and Allodynia by thewithdrawal threshold test using Von Frey Filaments at 1, 7, 14, 21, 28, 35,42, 49 and 56 days after SCI. The statistical comparisons between groupswere carried out by using repeated measures analysis of variances(ANOVA).Significant differences were observed in BBB scores in the Co- transplantgroup compared to the BMSC and SC groups (p< 0.05). There were alsosignificant differences in the withdrawal threshold means between animals inthe sham group and the BMSC, SC and the Co-transplant groups(p<0.05).BBB scores and withdrawal threshold means showed thatco-transplation improved functioning but greater Allodynia compared to theother experimental groups.The present study has shown that, although transplantation of BMSCs, SCs anda combination of these cells into the injured rat spinal cord can improvefunctional recovery, it leads to the development of mechanical Allodynia.This finding indicates that strategies to reduce Allodynia in celltransplantation studies are required. Spinal cord injury (SCI) is one of the most disabling diseases which leads to neuraltissue damage, significant sensorimotor deficits and disruption of autonomic nervoussystem control in areas caudal to the injury site . Injury Allodynia is an abnormal pain syndrome in which innocuous stimuli gain the ability toproduce pain. Epidemiological studies have reported that more than 64% ofpatients with spinal cord injuries suffer from chronic pain syndromes .Allodynia has various physical and psychological effects on patients which compromisetheir quality of life  and theyDifferent researchers have demonstrated that transplantation of stem cells like bonemarrow stromal cells (BMSCs) , SchwannIn this experimental research, adult female Wistar rats (n=40)  weighting (250-300g) were used. All procedures in this study,including the use of animals, were approved by the Research Council of TehranUniversity of Medical Sciences , Ethics Committee on AnimalExperiments whose guidelines are in agreement with those of the NationalInstitutes of Health for the use of live animals.Bone marrow was isolated in sterile conditions from 8 weeks-old male SpragueDawley rats weighting (250-300g) as described in detail by Azizi et al. . BrieflyAfter 48 hours, the non-adherent cells were removed by replacing the medium, whenthe adherent cells had grown to 80% confluency they were removed byincubation in a solution containing 0.25% trypsin and 1 mM EDTA  at 37℃ for 5 minutes and passaged. BMSCs were subcultured 4times in this way.The cells were labeled with bromodeoxyuridine (Brdu) at a concentration of3µg/ml which was added to the incubation medium 3 days prior totransplantation.SCs were obtained from the sciatic nerves of adult female wistar rats (10 weeksold) weighting (250-300g), as described by Morrissey et al. . BrieflyUnder sterile conditions and using a dissecting microscope the epineuruim wasremoved with a fine forceps, then the nerve washed 3 times with PBS andtransferred to a dish containing 10% FBS  and 1.25 IU/mldispase , 0.05% collagenase type IA  andincubated for 3 hours. Then the cell suspension was centrifuged at 800 rpm for5minutes, the supernatant was discarded and the pellet was washed with mediumand resuspended in DMEM supplemented with 10% FBS, 100 U/ ml penicillinand 100µg/ml streptomycin .3 flasksand incubated in 5% CO2 at 37℃ in medium containing10% FBS. After 2 days, non-adherent cells were removed by replacing themedium and the adherent cells were allowed to reach to confluent state. Once theadherent cells had reached 80% confluency the medium was replaced with0.25% trypsin and 1mM EDTA  and incubated at 37℃for 5minutesThe cell suspension was counted using a hemocytometer and placed in 25cm3 flasks. The cells were subcultured once a week.Cell dissociation from the substrate was monitored using an inverted microscope until the maximum amount of cells had been lifted. Thecell suspension was transferred into a 15ml tube and 10ml PBS was added. Aftercentrifugation the supernatant was removed and replaced with complete medium,and transferred to two 25cmAfter SCs have been enzymatically stripped from the sciatic nerve by incubationwith collagenase and dispase, a considerable population of fibroblasts remainswithin the preparation. For removal of these fibroblasts from the SC culture,the culture was incubated with the antimitotic cytosine arabinoside  24 hours after the cells was first isolated as, afteSCs cultured alone in vitro divide extremely slowly, but may be stimulated toproliferation by some mitogens. To stimulate the proliferation of SCs in thiscase the culture was incubated with mitogen Forskolin  .6 cells/ml in α‒MEM, and DiI was added at5µl/ml in α‒MEM. After incubation for 20 minutes at 37℃with 5% humidified CO2, the cells were centrifuged for5minutes and washed twice with PBS and were then resuspended in phosphate buffersaline (PBS) for transplantation  prior to transplantation. For labeling, the cells wereresuspended at 1×10Female adult wistar rats weighting (250-300g) were used for SCI model. Theanimals were anesthetized using intraperitoneal ketamine (80mg/ kg) and xylazine(10 mg/kg). Rats were placed prone on an operating table covered with a warmingblanket. After shaving the mid-thoracic region and prepping with Betadine, anincision was made over the mid-thoracic region. Laminectomy was performed at the(T8-T9) level of the spinal cord. A standard spinal cord contusion was madeusing the New York University (NYU) weightdrop device.A metal rod 10 g in weight and 2 mm in diameter was dropped from a height of 12.5mm onto the exposed spinal cord at the T8 level to cause moderate contusion.Then the wound was closed and postoperative care included manual bladderexpression 2 times a day, administration of Ringer's solution to avoiddehydration  and administration of gentamicin during the week after surgery. Analgesia was achieved usingbuprenorphine (0.1 mg/kg) for 2 days after surgery. Passive mobilization of thehind legs for 15 minutes was undertaken every day for a week after surgery.Four animals were killed 4 weeks after spinal cord injury. Animals were deeplyanesthetized with sodium pentobarbital  and were transcardiallyperfused with 4% paraformaldehyde in 0.1 mol/L PBS, pH=7.4.Tissues were cryoprotected in 30% sucrose overnight and a 1.5 cm segmentof spinal cord containing the zone of the injury was removed, embedded incryo-preservation medium (OCT) and cut transversely into 8µm serialsections. Sections were stained with Cresyl Violet Staining for the examinationof general morphology.The rats were randomly divided into 5 groups: 1. control group (n=8) inwhich only a laminectomy was performed; 2. sham group (n=8) in whichserum was administered by intraspinal injection; 3.5 SCs) by intraspinalinjection; 5. co-transplant group (n=8) which received (3×105BMSCs and SCs) in the same way.BMSC group (n=8) which received (3×105 BMSCs) by intraspinal injection; 4.SCs group (n=8) which received  through acustomized needle  with a sterile 30- gaugeneedle. A small hole was made in the dura at the injection site. Then thecustomized needle was inserted into the spinal cord at the midline to a depth of1 to 1.5 mm. 0µl of the cell suspension was then injected over 2 minutes.at a distance of 1mm rostrally and then 1 mm caudally from the site of injury.The needle was left in place for 2 minutes after injection before withdrawal tominimize cell leakage.After each transplantation session, 1 sample of BMSCs and SCs from the Hamiltonsyringe was mounted onto a slide and stained with trypan blue to assess cellviability. The SCs and the combination of BMSCs and SCs were transplanted intothe spinal cord in the same manner. The sham group had serum'transplanted' in the same way.Locomotor activity was evaluated over a period of 5 minutes using the open-fieldwalking test. One animal at a time was allowed to move freely inside a circularplastic tray .Two independent examiners observed the hind limb movements of the rat and scoredthe locomotor function according to the Basso Beattie and Bresnahan scale  that ranges from 0  to 21 points . The finalscore for each animal was the mean value of both examiners. During the openfield activity the animals were also video monitored with a digital camera.Functional tests were performed before the injury and transplantation and weeklyfor 8 weeks after transplantation.Mechanical sensitivity in the rats hind paws was assessed using Von FreyFilaments before and weekly for 8 weeks post transplantation, as described byPitcher et al .. The witThe platform on which the test was performed consists of a transparent plasticbox. This box has 1.5 mm diameter holes in its base through which Von FreyFilaments were applied to the plantar surface of the animal٫s hind paws.Filaments consist of hairs ranging from 0.008 to 300g which were applied todetermine the hind paw withdrawal threshold.The animals were placed in the testing box for 15minutes before testing forhabituation. All 4 paws were in contact with the platform. After applying theVon Frey Filaments in ascending order, every complete removal of the hind pawfrom the platform was considered as a withdrawal response. The test wasperformed 5 times with 5 second intervals. The force of filaments caused hindpaw withdrawal and this force in grams demonstrated the paw withdrawal thresholdfor 4 of 5 consecutive applications.When the paw withdrawal threshold had been determined for the Right hind paw, theprocedure was repeated for the Left hind paw.Rats were sacrificed 8 weeks after transplantation and were deeply anesthetizedwith sodium pentobarbital (100mg/kg. ip) and were transcardially perfused with4% paraformaldehyde .Tissue was cryoprotected in 30% sucrose overnight and a segment of thespinal cord 1 cm in length from the injury site was removed, embedded in OCT andcryosectioned transversally into 8µm serial sections.BMSCs which had been labeled with Brdu prior to transplantation were identifiedaccording to the following procedure . The secAfter rinsing 3 times in PBS for 10min, they were incubated again overnight inthe dark at 4℃ with fluorescein isothiocyanate (FITC) conjugatedsecondary antibody (1:100) . TheyweTo identify and evaluate the purity of the Schwann cells, immunoassay of S100 wasperformed according to following procedure: The sections were washed 3 times inPBS for 6 minutes, incubated for 30 min in blocking solution [1× PBS +0.1% Triton X +2% normal goat serum (NGS)], then incubatedovernight at 4℃ with cell marker primary antibody . After rinsing 3 times in PBS, they wereincubated with FITC conjugated secondary antibody in the dark at roomtemperature for 60 minutes. The sections were mounted onto gelatin-coated glassslides and were analyzed under a fluorescent microscope.The statistical comparisons between groups were carried out using repeatedmeasures analysis of variance (ANOVA) followed with the tukey test for post hocanalysis.Statistical analysis was performed using SPSS version 15. A p<0.05 wasaccepted to denote statistically significance and all data were presented as(mean ± SEM).BMSCs and SCs were cultured in DMEM medium. When they had grown to 80%confluency they were subcultured 3 and 4 times respectively .Four weeks after contusion injury observation of sections which stained withcresyl-violet indicates that vacuoles and cystic cavities of different sizes hadformed at the site of injury. This cyst formation is due to the death ofneurons, interneurons and glial cells after SCI.Immunohistochemical findings showed that transplanted BMSCs and SCs survived atthe site of injury 8 weeks after transplantation. Figure 2A shows DiI labeledSchwann cells, identified by fluorescent microscopy, and figure 2B shows Brdu-positive BMSCs survived and gathered around the injury site.Prior to SCI rats in all 3 experimental groups had a BBB score of 21 points. Oneday after SCI, the contused rats demonstrated considerable loss of hind limblocomotor function with no movement and BBB scores of 0-1 points.th day post operation (DPO), mean ± SEM BBBscores were 8.12 ± 1.12 in the sham group, 10.25 ± 1.28 in the SCgroup, 10.62 ± 1.30 in the BMSC group and 10.75 ± 1.16 in theco-transplant group.On the following days the BBB score increased considerably in all groups. Forexample on the 14From weeks 3-8 animals in the SC, BMSC and co- transplant groups exhibited aprogressive increase in their hindlimb movements in comparison to the sham group(p<0.05)  , 4.th and 8th weeks walking skills among the rats inthe co-transplant group improved significantly compared to the SC and BMSCgroups. Moreover, the animals in the co-transplant group displayed consistentweight supported plantar stepping and demonstrated consistent fore-hindlimbcoordination, whereas the animals in the SC and BMSC groups showed modestfore-hindlimb coordination.In the 7A BBB score of 21 was obtained by animals in the control group during all stagesof the study. The average BBB scores for animals in the sham, SC, BMSC andco-transplant groups were respectively: (11.12 ± 1.12), 13.5 ±1.06), 14 ± 0.75) and (15.87 ± 0.83) in the 8th week . Incontrast, the statistical difference between the SC and BMSC groups was notsignificant (p>0.05) Figs  , 4.The Von Frey Hair Test was performed weekly for 8 weeks for the assessment ofmechanical Allodynia Figs  , 6. In In the BMSC group the mean withdrawal threshold was (210± 19.64 g) infirst week, (80.75±10.09 g) in the second week, (56.5 ± 8.25 g) inthe third week, (41.63 ± 7.06 g) in the fourth week, (33.13 ± 6.01g) in the fifth week, (27.5 ± 4.96 g) in the sixth and seventh weeks, and(21.88 ± 2.01 g) in the eighth week. At the end of the eighth week therewas a significant difference between this group and the sham group(p<0.05) but no significant difference between this group and SC and theco-transplant groups (p> 0.05).In SC group, the mean withdrawal threshold was (185 ± 19.18 g) in firstweek, (70.75 ± 9.47 g) in second week, (47.25 ± 6.22 g) in thethird week, (41.63 ± 7.06 g) in the fourth week, (33.13 ± 6.01 g)in the fifth week, (30.38 ± 6.71 g) in the sixth week, (26.13 ±5.20 g) in the seventh week and (20.63 ± 5.62 g) in the eighth week. Atthe end of the eighth week there was a significant difference between this groupand the sham group (p< 0.05) but no significant difference between thisgroup and the BMSC or co-transplant groups (p> 0.05).In the co-transplant group the mean withdrawal threshold was (200 ± 23.90g) in the first week, (75 ± 7.31 g) in the second week, (56.5 ±8.25 g) in the third week, (47.25 ± 6.22 g) in the fourth week, (31.75± 6.39 g) in the fifth and sixth weeks, (30.38 ± 6.71 g) in theseventh week and (19.13 ± 2.01 g) in the eighth week. At the end of theeight week there was a significant difference between this group and the shamgroup (p<0.05) but no significant difference between this group and theBMSC or SC groups (p> 0.05).The present study demonstrates that the co-transplantation of BMSCs and SCs into theinjured spinal cord of rats can improve functional recovery and also leads todevelopment of mechanical Allodynia. Our histological findings confirmed thecontusion model of injury had worked in the expected manner. The SCs were harvested and labeResults from the behavioral assessment (locomotor function) showed thatco-transplantation of BMSCs and SCs in an animal model of SCI can considerablyenhance locomotor recovery and may prove a beneficial method of treatment for SCIFigs , 4.The BBB scores observed in our study in the BMSC and SC groups in the eighth weekafter injury are very similar to scores found in other studies. For instance, thescores for BMSC injected animals in the study of Ohta et al.  and HofsThe data from the present study also indicates that co-transplantation of BMSCs& SCs into the injured spinal cord leads to an undesirable state namedmechanical Allodynia. Spinal cord injury is often followed by debilitatingneuropathic pain named Allodynia. Allodynia defined as increased sensitivity tonormally innocuous stimuli, in other words Allodynia is a painful response to anonpainful stimulus.Several hypotheses have explained for etiology of allodynia: the study of Seung etal. showed that loss of spinal µ-opioid receptors after peripheral nerveinjury result in allodynia .The findings of the present study indicate that transplantation of BMSCs and SCs anda combination of these cells into the injured rat spinal cord significantly decreasethe mean withdrawal threshold compared to a sham group which received only serum andany cell (p<0.05) . In otheThe findings of our study are similar to the studies of Hofstetter et al.  and MaciThe mean withdrawal threshold at the end of the eight week in the BMSC, SC andco-transplant groups were respectively (21.88 ± 2.01g), (20.63 ± 5.62g) and (19.13 ± 2.01g) which indicates that the mean withdrawal threshold inthe co-transplant group decreased further than in the BMSC and SC groups, suggestingthat co-transplantation of BMSCs and SCs can induce a higher level of allodynia.It is possible that BMSCs and SCs transplanted into the spinal cord may differentiatemainly into astrocytes which provide NGF. NGF in turn can cause aberrant axonalsprouting in neurons of the dorsal horn which is associated with nociception andresults in Allodynia. It is also possible that cotransplantation of BMSCs and SCsleads to more NGF production and more axonal sprouting in the dorsal horn which thusresults in enhanced Allodynia.The present study has also shown that although co-transplantation of BMSCs and SCs inan animal model of SCI can considerably enhance locomotor recovery. It also inducesundesirable pain i.e. allodynia.Some methods of reducing allodynia have been reported in a number of studiesincluding: Transplantation of GABAergic cells ; graftinOur findings have shown that co-transplantation of BMSCs and SCs may provide apowerful therapy for SCI. Further research is required for the development ofcombinatory treatment strategies in the future. The study has also shown thatcotransplantation of these cells may lead to an increase in allodynia. For thisreason future stem cell therapy programs should focus on combinational therapy usingthese cells at the same time as applying methods which can decrease theallodynia.