A lack of anaesthetic monitoring and the absence of supplemental oxygen were shown to be significant risk factors for mortality. Hyperthermia, likely to be associated with capture stress, was the most common reported complication (35%). The results suggest that free-ranging rather than habituated captive cheetahs are particularly at risk of dying during immobilisation and transport. The capture-related fatalities in this species do not appear to be associated with either the veterinarian’s level of clinical experience or the immobilisation agents used.The objective of this study was to gain better insight into factors associated with the capture-related mortality rate in cheetahs. A link to an online questionnaire was sent to zoo and wildlife veterinarians through the Species Survival Plan Programme and European Endangered Species Programme coordinators and via the ‘Wildlife VetNet’ Google group forum. The questionnaire consisted of 50 questions relating to the veterinarians’ country of residence and experience, the medicine combinations used, standard monitoring procedures, capture-related complications and mortalities experienced in this species under different capture conditions. In addition, necropsy data from the national wildlife disease database of the National Zoological Gardens of South Africa were examined for cases where anaesthetic death was listed as the cause of death in cheetahs. A total of 75 veterinarians completed the survey, with 38 from African countries and a combined total of 37 from Europe, the United States (US) and Asia. Of these, 24% ( Acinonyx jubatus) have suffered drastic population declines because of several anthropogenic factors that now confine them to a mere 9% of their historical distribution range. More than half of the world’s estimated 7100 free-ranging individuals currently reside in six southern African countries  and the lesions listed in the necropsy reports were recorded.The questionnaire consisted of 50 questions that required either a checkmark, numeric answers or comments. Questions 1–11 asked about the veterinarians’ year of graduation, country of residence and experience in cheetah immobilisation. Questions 12–23 asked about common chemical capture protocols and anaesthetic monitoring used in different situations. Questions 24–50 asked about the objective of the immobilisation, the complications and the mortalities experienced with this species. Microsoft Excel was used to create a database and to enter the data from the survey. In addition, as few necropsy reports were available for the cheetahs’ mortalities reported in response to the questionnaire, the wildlife disease database of the National Zoological Gardens of South Africa (NZG) was examined for cases where anaesthetic death was listed as the cause of death in cheetahs  and 95% confidence intervals (CIs) were calculated for each potential risk factor. Odds ratios measured the association between a risk factor and peri-anaesthetic death. Risk factors were those with OR > 1 and protective factors had OR < 1. All analyses were performed with R Studio . A The survey study was approved by the National Zoological Gardens of South Africa’s Research and Ethics Committee (P17/06) and by the Animal Ethics Committee of the University of Pretoria (V025-17).Completed online surveys were received from 75 veterinarians: 50.7% (38/75) were from Africa, 36.0% (27/75) from Europe and Asia and 13.3% (10/75) from North America. More than half  of the veterinarians from Africa who completed the survey had been practising for more than 10 years, while just fewer than a third  of veterinarians from Europe, North America and Asia had been practising for this length of time. Just about half  of the responses were from veterinarians working in zoos with the majority of these practising in Europe  and North America . Twenty-seven private wildlife practitioners completed the survey , with the majority  working in Africa.−1) was the combination most often used for chemical capture (47.0%) under various captive and free-ranging conditions, followed by medetomidine and a tiletamine-zolazepam combination (0.04–0.06/1.20–1.54 mgkg−1) (27.9%) and medetomidine, butorphanol and midazolam (0.031–0.039/0.20–0.26/0.13–0.18 mgkg−1) (8.7%) (Ketamine and medetomidine (2.37–3.25/0.048–0.073 mgkg) (8.7%) .−1) in 63.5% or medetomidine (0.014-0.02 mgkg−1) in 19.1% of cases. Maintenance of anaesthesia, through isoflurane inhalation (1.0%–4.0%) was provided in 28.4% of cases.Supplemental anaesthesia was often achieved with intravenous (IV) ketamine (0.84-1.43 mgkg2) or end-tidal carbon dioxide (EtCO2)] during chemical capture. When monitoring was actively performed, respiratory rate (97.8%), rectal temperature (95.6%) and heart rate (94.5%) were the parameters they most often recorded. Oxygen saturation (61.5%) and an assessment of dehydration status (40.66%) were partially recorded, whereas capnography and electrocardiography (ECG) data were almost never recorded. Oxygen supplementation and fluid administration (subcutaneous or IV route) were only provided in 27.8% and 47.0% of cases, respectively.Almost a quarter (21.7%) of the veterinarians did not record any of the basic physiological parameters [heart rate, respiratory rate, rectal temperature, blood oxygen saturation (SpOn = 18/75) of veterinarians had faced at least one capture-associated cheetah mortality in their career. The majority of the deaths were experienced by veterinarians working in Africa . Of these, 14/18 (77.8%) had immobilised more than 50 cheetahs in their careers. Most encountered only a single death (n = 12/18), one faced two deaths, three experienced three deaths and one faced a total of nine fatalities.Twenty-four per cent , followed by respiratory arrest (17.3%), hypoxaemia (16.0%), hypothermia (12.0%), transient seizures (12.0%), trauma (9.3%) . The misn = 13/30) were immobilised in an enclosure or boma or from a vehicle , while relatively few were immobilised in a transport crate  or from a helicopter . A large proportion of the cheetahs that died were subjectively judged by the surveyed veterinarians to be stressed at the time of capture , whereas 16.67% (5/30) were considered calm and 16.67% (5/30) alert.We received data through the survey for 30 capture-related cheetah mortalities from 18 veterinarians. The records included three juveniles (< 1 year), five subadults (< 2 years) and 22 adults, corresponding to 23 male cheetahs and 7 female cheetahs. The majority of deaths were reported in individuals captured for translocation purposes (17/30) followed by cheetahs immobilised for health examinations (6/30), other procedures (4/30) and the fitting of telemetric collars (3/30). The majority  was the combination administered most in cheetahs that died (n = 10/30). This is followed by the use of tiletamine-zolazepam alone (3.954 ± 0.768 mgkg−1) (n = 8/30), ketamine and xylazine (2.736 ± 0.77/3.42 ± 0.962 mgkg−1) (n = 6/30), medetomidine and ketamine (0.067 ± 0.025/4.356 ± 3.517 mgkg−1) (n = 5/30) and medetomidine, butorphanol and midazolam (0.034/0.231/0.143 mgkg−1) (n = 1/30). Only one of the cheetahs received a specific tranquilliser prior to transportation (10 mg of diazepam).No specific medicine, dose or any of the medicine combinations were statistically associated with the mortalities. Medetomidine and tiletamine-zolazepam (0.051 ± 0.017/1.090 ± 0.260 mgkgn = 13/21). Six individuals had rectal temperatures between 39 °C and 40 °C (28.57%) and only two were lower than 39 °C (9.52%). Extreme hyperthermia with rectal temperatures of 43 °C or above was noted in three cases. For cheetahs that presented with hyperthermia, cooling was attempted by pouring water on the animal in 12/13 cases. Intravenous fluid therapy was provided to 43.3% (13/30) of animals that died and 16.67% received oxygen supplementation. The majority of deaths 12/30 (40%) occurred at least 1 hour after immobilisation, 9/30 (30%) after antidote administration, 7/30 (23.3%) between 30 minutes and 1 h after immobilisation and only 2/30 (7%) within the first 30 min of immobilisation.No anaesthetic monitoring was performed for 5 of the 30 cheetahs. Respiratory rate and rectal temperature were the only values recorded for 17 and 21 of the animals, respectively. Where rectal temperature had been recorded, hyperthermia (> 40 °C) was noted in 61.9% of cases (n = 2) or excellent (n = 3). In 10 cases, variable combinations of tissue congestion, pulmonary oedema, renal tubular necrosis, periacinar hepatocellular degeneration or necrosis were present. Terminal aspiration of stomach contents was seen in six cases and tracheal haemorrhage, alveolar atelectasis or haemorrhage in three cases. Suspected bronchospasm was seen in two cases and laryngeal oedema in one case. There was no evidence of pre-existing significant pathology in seven cases. Five animals had pre-existing disease that may have played a role in their deaths including four animals with septicaemia and/or toxaemia, one of which also had hepatic veno-occlusive disease and mild chronic renal disease, while another also had mild myocardial fibrosis. One other cheetah had mild myocardial fibrosis. One cheetah had widespread vasculitis of unknown cause and died of cardiac tamponade. Enlarged and/or hyperplastic adrenal glands were noted in six animals. Subacute lymphoplasmacytic gastritis and mild chronic renal disease were each noted in five animals and gastric ulcers and splenic myelolipomas each in one animal.Necropsy reports of 13 cheetahs  were collected from the NZG wildlife disease database. In those cases, a complete set of tissues was not submitted for examination and autolysis of some individuals precluded data evaluation in detail. Body condition, where noted, was described as good (p = 0.027) and partial monitoring, without the evaluation of SpO2 , was significantly associated with increased risk. Oxygen supplementation was shown to be a protective factor . Combinations of medicines, veterinarian experience and chemical capture conditions (boma vs. helicopter vs. vehicle vs. crate) were not considered significant risk factors for mortality.The multivariate logistic regression model created to examine the relationship between veterinarians’ characteristics, immobilisation medicine combinations and capture complications identified two risk factors associated with mortality. A failure to record and monitor physiological parameters during chemical capture , three out of nine Eurasian lynx (Lynx lynx) and two out of three grey wolves (Canis lupus) , leopards (Panthera pardus) and lions (Panthera leo) , the use of icepacks and dousing with copious amounts of water (between 4 °C and 28 ᵒC) were the most effective methods of reducing body temperature. The peripheral vasoconstrictive and impaired thermoregulatory effects of the α-2 agonists may, however, significantly impede active cooling techniques. Tordiffe  was identified as a risk factor for mortality. This, together with oxygen supplementation, which was identified as a protective factor, suggests that hypoxaemia may contribute to the mortalities in some cases. Veterinarians who record a variety of anaesthetic monitoring data may simply identify deteriorating clinical parameters and intervene earlier, thus improving survival rates. Mild to moderate hypoxaemia has been reported in cheetahs anaesthetised with tiletamine-zolazepam together with ketamine and xylazine  that occurred after the anaesthetic antidotes were administered. Stormy recoveries have been reported in cheetahs if the primary αThe study was limited to some extent by the number of questions that we felt we could ask because of concerns that veterinarians would not participate in the survey if it took too long to complete. In retrospect, the addition of a few key questions would have added some important information that would have provided more clarity on certain aspects of the study. For example, we failed to ask veterinarians about the exact number of cheetahs that they had immobilised in their career. If we had that information we would have been able to provide estimated mortality rates. We also failed to ask specific questions about the antidotes  that were given in cheetahs that died after they were administered. In addition, the 30 deaths reported represent a relatively small number for statistical analysis, especially because almost a third of the reported fatalities were reported by one veterinarian. Nevertheless, the study does provide some important information on factors that can be addressed to reduce capture-related mortalities in this species.The survey results suggest that free-ranging rather than habituated captive cheetahs are particularly at risk of dying during immobilisation and transport. The stress associated with capture in these free-ranging animals may make them particularly susceptible to hyperthermia and other anaesthetic complications. The capture-related fatalities in this species do not appear to be associated with either a lack of experience on the part of the attending veterinarian or the particular drug combination used for immobilisation. The survey highlights the need for more active monitoring of cardiovascular and respiratory parameters and the provision of supplementary oxygen, particularly in cheetahs anaesthetised for periods longer than an hour. Anaesthetic monitoring and the management of stress after antidote administration also need to be improved. The availability of a portable isoflurane anaesthetic machine, suitable monitoring equipment, an adequate supply of oxygen and a large supply of cold water and/or ice packs should perhaps be considered essential equipment for veterinarians working with cheetahs in the field.


Infertility is responsible for a major cost burden for patients and health care systems. Therefore identifying preventable risk factors for infertility may contribute to the development of more cost-effective approaches to solving the infertility problem. However, such investigations have never been conducted in Morocco. Thereby, the objective of the present study was to determine the occurrence and distribution of these factors among Moroccan infertile couples. This retrospective study included 1265 infertile couples who attended the Assisted Reproductive Technology Unit of the Reproductive Health Centre of the University Hospital Ibn Sina in Rabat. All couples had been infertile for at least 1 year and both partners were fully investigated. Couples had primary and secondary infertility in 77.2% and 22.8% of cases, respectively. Women were overweight in 47.9% of cases and obese in 25.8% of cases while men were overweight in 44.6% of cases and obese in 14.7% of cases. 18.9% of women and 17.5% of men had a previous abdominopelvic or urogenital surgery. A history of sexually transmitted infection was reported by 7% of men and 5.8% of women. A history of tuberculosis was found 9.3% of women and 4.8% of men. In addition, 31.7% of men were cigarette smokers and 8.4% consumed alcohol. The study showed that preventable risk factors of infertility are common among Moroccan infertile couples. However, additional studies are required to investigate each factor and its relation to infertility in the Moroccan population. Reproduction is one of the naturally desired human purposes and is indispensable for the continuation of every society . HoweverIn this retrospective study the medical records of 1265 infertile couples attending the Assisted Reproductive Technology Unit of the Reproductive Health Centre of the University Hospital Ibn Sina in Rabat, from October 2013 to March 2017, were reviewed. The complete history of all patients was detailed and a complete physical examination was conducted. Only couples who had been infertile for at least 1 year, whose investigation had been completed and of whom both partners had received a diagnosis, were admitted to the study. For men, the history of pubertal development, cryptorchidism, inguinal surgery, orchitis, testicular torsion, sexually transmitted diseases, cigarette smoking, alcohol consumption, drugs or hormones intake as well as a history of exposure to chemicals were documented. The physical examination evaluated the size and position of the testes and the presence of varicocele and any other congenital or acquired anomalies. For women, a particular attention was paid to the pattern of pubertal development, menstrual history, abdominal and pelvic surgery, cigarette smoking, alcohol consumption, drugs or hormone intake and sexually transmitted diseases. Sexual history focused on libido, erectile function, frequency and timing of intercourse. A detailed gynecologic examination was performed to ascertain congenital or acquired anomalies or diseases such as endometriosis. Specific investigations were carried out for the male partner including semen analysis and semen culture. Hormone analysis, ultrasonography and Doppler ultrasound of the scrotum were performed in some cases. Semen analysis was done according to the World Health Organization laboratory manual. For the female partner, the specific investigations performed included hormone analysis, ultrasonography and hysterosalpinography for tubal patency assessment. Hysteroscopy was performed in some cases. Laparoscopy was done when indicated to study tubal anomalies and to look for endometriosis. Statistical analysis was performed using the software package SPSS 20 (IBM) . The study was approved by the Ethics Committee of Biomedical Research of the University Mohammed V of Rabat, Morocco.2  and the median body mass index of men was 26 ± 3.8 Kg/m2 . An ovulatory disorder was identified in 177 (14%) women with an overweight and in 120 (9.5%) obese women. Moreover, 136 (10.8%) overweight women and 81 (6.4%) obese women had a polycystic ovary syndrome.Among the female partners, 18.9% had previous abdominal or pelvic surgical treatments. Appendicitis, peritonitis, and intestinal occlusions were reported in 33 (2.6%), 7 (0.5%) and 2 (0.2%) cases, respectively. In 9 cases, the patients could not remember the type of surgery. Fifteen (1.2%) women who had appendectomies and all the women who were operated for peritonitis and intestinal occlusions presented a tubo-peritoneal factor. The history of surgical treatment showed that 17.5% of men had abdominal or urogenital surgery. Eighteen (1.4%) men had surgery for inguinal hernia. Twenty-six (2.1%) men had unilateral or bilateral orchiopexy for undescended testicle diagnosed at an advanced age among them 3 patients (0.2%) had unilateral orchiectomies. Unilateral or bilateral varicocele ligations were performed in 117 (9.2%) men and 2 (0.2%) patients had orchiectomies after a testicular injury.This study included 1265 infertile couples. The median age of men was 39 ± 7 years , and the median age of women was 32 ± 5.4 years . The infertility was primary in 977 (77.2%) couples and secondary in 288 (22.8%) couples. The median duration of infertility at the time of the first medical consultation in the infertility unit was 5 ± 4 years . The age range for menarche was between 10 and 19 years (median 13 ± 1.4 years). A history of sexually transmitted infections was found in 73 (5.8%) women and 13 (1%) of them had a pelvic inflammatory disease. A tubo-peritoneal factor was found in 44 (3.5%) women with a previous history of sexually transmitted infections, and in all patients with a previous history of pelvic inflammatory disease. On the other hand, 118 women reported a history of tuberculosis, 82 (6.5%) of these women had a tubo-peritoneal factor. For men, sexually transmitted infections were mentioned by 89 (7%) patients and 7 of these men (0.5%) had obstructive azoospermia. Furthermore, 61 men reported a history of tuberculosis and 18 (1.4%) of them had an obstructive azoospermia. Among the 288 couples with secondary infertility, 94 women had vaginal delivery, 46 had cesarean delivery, 70 had a spontaneous abortion and 37 had an ectopic pregnancy. Thirty-nine women reported that they previously had an induced abortion and 2 women had a history of molar pregnancy . None ofChlamydia trachomatis, which is one of the leading organisms responsible for sexually transmitted diseases [Chlamydia trachomatisurogenital tract infection is chronicity and persistence", inducing silent infections [Chlamydia trachomatis in male infertility is still controversial [Chlamydia trachomatis, Neisseria gonorrhea's infection is highly associated with infertility [Neisseria gonorrhea can also cause acute pelvic inflammatory disease and subsequently irrevocable tubal damages [The last decades were characterized by various modifications affecting socio-economic and environmental conditions and leading to profound lifestyle changes . In factdiseases , 12, wasdiseases . Howeverfections , 12. Thefections ,12. Althoversial , 11, 12.ertility . Frequen damages . In most damages .Neisseria gonorrhea was reported by 2% of men and 0.9% of women and Trichomonas vaginalis was mentioned by 1.8% of women and 0.9% of men. These are low frequencies compared to the Mongolian study where Gonorrhea was mentioned in 26.3% of men and in 14.9% of women and Trichomoniasis was reported in 10.2% of women and in 9.1% of men [Trichomonas vaginalis, which is frequently asymptomatic, has the ability to affect the upper genital tract and untreated the parasite can persist for 3 to 12 months in the genital tract [Trichomonas vaginalisinfection have about twice the risk for a tubal infertility [Trichomonas vaginalis might enable the dissemination of other pathogens throughout the upper genital tract, thereby indirectly causing infertility [In the present study, ertility . The proMycobacterium tuberculosis affects the fallopian tubes in 92-100% of cases, the endometrium in 50% of cases and the ovaries in 10-30% of cases [In addition to sexually transmitted pathogens, other infectious diseases can also impair fertility such as genital tuberculosis whose incidence ranges from less than 1% in developed countries to almost 13% in the developing world , 16. Theof cases . This inof cases . In our of cases . Tubal iof cases . In factof cases . Peri-tuof cases . In a reof cases . Similarof cases . Concernof cases . In our 2. The effects of overweight and obesity on women's fertility have been well established [2 of the probability of spontaneous conception in women with a body mass index >29 kg/m2. Secondly, obesity has a negative impact on assisted reproductive technologies outcomes [2 are enrolled in a weight loss program. In men, although high body mass index has been identified by large population studies as an independent risk factor for infertility, its relationship with sperm quality remains controversial. In fact, some studies established that there was a strong correlation between obesity and sperm parameters while other studies found no significant correlation [Another factor increasingly associated with the inability to conceive is obesity and overweight. In Morocco, 22% of women and 8% of men are obese . This phablished . First, ablished . A case-outcomes . Studiesoutcomes , 20. Cycoutcomes , 20. Thirelation , 21. On relation .In addition, it was demonstrated that overweight and obesity have a statistically significant positive correlations with DNA fragmentation index . This inSexually transmitted diseases, tuberculosis, obesity, cigarette smoking, alcohol consumption are all preventable infertility risk factors. This study showed that these factors are common among infertile couples. However, additional studies are required to investigate each factor and its relation to infertility in the Moroccan population. On the other hand, the study findings highlighted the possibility and necessity of preventive measures to solve the infertility problem before having recourse to expensive assisted reproductive treatments. Information, education and communication programs are cheaper; promote safer sexual behaviors and contraception; and enhance awareness of obesity and cigarette smoking health consequences.Sexually transmitted diseases represent the most important and most preventable risk factors for infertility;The incidence of tuberculosis ranges from less than 1% in developed countries to almost 13% in the developing world;Obesity and overweight are a global and major concern to public health.All the study women with a previous pelvic inflammatory disease had a tuboperitoneal infertility;There is a high frequency of overweight and obesity among the study population;The study women with a tubo-peritoneal factor had a history of tuberculosis in 24.3% of cases.The authors declare no competing interest.


Pseudomonas aeruginosa is an increasing health problem. Integrons are associated with a variety of gene cassettes, which confer resistance to multiple classes of antibiotics. This study aimed at screening the presence of class 1, 2 and 3 integrons in P. aeruginosa in Yazd, Iran.Antibiotic resistance in P. aeruginosa strains from March 2016 to March 2017. Clinical specimens were initially identified by the standard biochemical methods and their resistance patterns to antibiotics were studied using the disc diffusion method. PCR was carried out for the detection of class 1, 2 and 3 integrons using intI1, intI2 and intI3 gene primers, respectively.This study was carried out on P. aeruginosa isolates carried intI2 and intI1 genes, but intI3 gene was not found.Antimicrobial susceptibility test showed that 75% of isolates were detected as multi-drug resistant (MDR), and lowest resistance was observed in ciprofloxacin (48.6%) and most resistance was in gentamicin (63.2%). Moreover, PCR results showed that 22 (15.3%) and 119 (82.6%) of P. aeruginosa isolated from clinical samples, they are often responsible for antibiotic resistance gene transfer, which calls for evaluation of integrons as contributing factors in antibiotic resistance.Since it is customary to observe Class I integrons in  Pseudomonas aeruginosa are the leading Gram-negative pathogen bacteria associated with nosocomial infections  and integrase gene (int I) , whose products are 46% and 61% identical to class 1 integrase, respectively  . There h (int I) –8, wherentI gene . HoweverntI gene . Class 2ntI gene . Arakawad so far . Class 2ectively –16 showeP. aeruginosa strains isolated from clinical specimens in Yazd, Iran.The aim of the present study was to find out the molecular relation and the existence of integrons with multidrug resistance pattern of P. aeruginosa which were collected from Shahid Sadoughi Hospital, Yazd, from March 2016 to March 2017. A questionnaire was used for recording patient demographic data such as: name, age, sex, type of sample, and ward. Bacterial isolates were recovered from different clinical specimens such as blood, bronchial fluid, urine, cerebrospinal fluid, catheter, pleural fluid, ear swap, sputum, and wound and inoculated on sheep blood agar and EMB agar media before incubation at 37°C for 24 h. All isolates were identified as P. aeruginosa using standard biochemical tests like growth on Cetrimide agar medium , growth at 42°C, oxidase test, gram stain, pigment production, and Oxidation/Fermentation test.This descriptive study was carried out on 144 clinical isolates of P. aeruginosa ATCC 27853 was used as a control.Antimicrobial susceptibility testing were performed using the disk diffusion method according to CLSI guidelines  for gentP. aeruginosa isolates was performed by salting out method and were stored at −20°C until use (2 (100 mM), 0.5 μl dNTP (10 mM), 0.2 μl (1 unit) Taq DNA polymerase , 1 μl of each primer (10 pmol) , 2.5 μl PCR buffer (10 X), and 0.5 μl of DNA template (100 μg/ml) in total volume of 25 μl with double distilled water. DNA amplification was performed in the thermo cycler  using an initial denaturation step for 5 min at 94°C (one cycle), followed by 35 cycles of 1 min at 94°C, 1 min at 50°C and 1min at 72°C for intI1. The above condition was used for intI2 and intI3 the same as the one for intI1 but in annealing temperature at 47°C and 52°C, respectively. All of the reactions were finalized for 5 min at 72°C (one cycle). Amplicons were analyzed by electrophoresis on 1% agarose gels at 5V/Cm alongside with 50 bp DNA ladder. To confirm the amplicons, some isolates were sequenced and analyzed with bioinformatics software such as BLAST and ClustalW2 (Extraction of genomic DNA from ntil use . Specifintil use . The finP<0.05).The data was analyzed using the SPSS18. The Chi-square test was employed to calculate the P-value in terms of resistant numbers of integron-positive and integron-negative isolates (P. aeruginosa isolates showed the most resistance against gentamicin (63.2%) and imipenem (62.5%), respectively. The lowest resistance rates were seen against ciprofloxacin (48.6%) and piperacillin (54.9 %), respectively. One hundred and eight strains (75%) were resistant to more than three groups of antibiotics (MDR). Forty strains (27.7%) were resistant to all tested antibiotic groups.Seventy-nine out of 144 patients (54.9%) were male and 65 (45.1%) were female. Their age ranged from one month to 79 years with a mean of 34.9+22.7 (+SD) years. The isolates were obtained from different clinical specimens including burn wounds (43.8%), urine (23.6%), tracheal fluid (13.9%), wound (6.9%), blood (6.3%), sputum (2.8%), and catheter (2.8%). The isolates were obtained from hospitalized patients in burn ward (47.2%), ICU units (18.8%), internal (16.7%), general surgery (12.5%), and neurology (4.9%) wards. P. aeruginosa isolates (intI1 and intI2 genes. No intI3 gene was detected in any of the isolates. A significant correlation was observed between the presence of integrons class 1 and resistance against gentamicin (Class 1 integron was detected in 119 (82.6%) isolates , of whicisolates  of whichntamicin , and alsntamicin . MoreoveThe nucleotide sequence data reported in this work was assigned to the NCBI/GenBank nucleotide sequence database under accession no. KF146819 and KF358999.P. aeruginosa multi-resistance, an important aspect that has been considered is the integron and the associated gene cassettes  of Kohanteb  and NikoKohanteb , it was P. aeruginosa in biomedical publications  isolates of ications . In the ications –26. Our n Brazil , Zhenjian Brazil  and Guiln Brazil  showed tConsidering that almost half of the samples were taken from a burn unit and 18.8% of the samples were collected from an ICU unit, the high prevalence of MDR cases can be justified in the present study. In this study, the highest antimicrobial resistance rate was observed for gentamicin (63.2%). The resistance rate against gentamicin was reported 55.8% in France in 2008  and 95% P. aeruginosa clinical isolates carrying class 1 integron in Iran vary between 39.4% and 56.3% . In order to prevent formation of P. aeruginosa strains which may be MDR, an antimicrobial susceptibility test, especially MIC, should be performed before starting the treatment, and adequate supervision is required for the use of antibiotics. Regarding the high prevalence of intI1 gene in this study (82.6%) and its effect on increasing the P. aeruginosa antibiotics resistance, determination of positive cases and precise detection of antibiotic susceptibility pattern is strongly recommended. Apart from whether the resistance genes are present in integrons, in this study there is noticeable relationship between the presence of integrons and increased resistance to many groups of antibiotics and this could be a concern because these structures can alter involved genes in resistance between strains so that these strains become resistant to new antibiotics.In this study, we observed high prevalence of MDR


This study was undertaken to analyze the immunohistochemical expression of fibroblast growth factor receptor (FGFR3) in urothelial carcinoma and correlate its expression with the pathological stage, recurrence and other clinicopathological parameters.A retrospective study was undertaken on paraffin blocks of 55consecutiveurothelial carcinoma specimens in 28 months received in Sri Ramachandra Medical College, Chennai, India. Blocks with the sections containing the tumor and adjacent normal epithelium were chosen for the immunohistochemical (IHC) study of FGFR3.IHC expression of FGFR3 in high grade (HG) invasive urothelial carcinoma was positive in 18% cases, 66.7% of HG non-invasive urothelial and 82.6% of low grade (LG) non-invasive urothelial carcinomas. P<0.05).The FGFR3 expression was presented in 78.1% of non-invasive carcinoma. In case of invasive urothelial carcinoma, the FGFR3 positivity was observed in 18.2% of tumors (P<0.05).FGFR3 expression in LG tumors was positive in 82.6 % of the cases whereas 32.3% of HG cases were positive for FGFR3 (P<0.05).FGFR3 was expressed in 14.3 % of HG invasive tumors which recurred. HG non-invasive tumors were positive for FGFR3 in 80% of the cases. LG non-invasive tumors were positive for FGFR3 in 72.7% of cases (The expression of FGFR3 is higher in low grade, non-invasive tumors and recurrent non-invasive tumors. The targeted therapy for FGFR3 may be used as one of the modes of treatment for urothelial carcinoma. It can also be used as a marker to determine the grade in difficult cases and the risk of recurrence. Bladder cancer is the seventh most common malignancy worldwide, accounting for approximately 3.2% of all cancers globally. It is more often seen in males than females. An estimated of 260,000 and 76,000 new cases occur each year in men and women, respectively .Urothelial carcinomas may present as papillary or flat neoplasms, majority of which are usually non-invasive. Diverse molecular pathways are implicated in the pathogenesis and development of non-invasive and invasive tumors .1 Bladder tumors have a high rate of recurrence and progression, thus, prognostic outcome for urothelial carcinoma remains unpredictable, demanding validation of important markers . Currently, the depth of invasion, histologic grade and margin status are the most important prognostic factors. However, several other parameters such as p53 expression, ki - 67, loss of E cadherin, CK 20 and FGFR3 mutations have been implicated as indicators of progression and recurrence of the tumor.Binding of the fibroblast growth factor receptor (FGFR) to the mutated FGFR3 tyrosine kinase receptor leads to the activation of downstream pathways including RAS- MAPK, PI3K and STAT6. These pathways regulate a number of cellular functions including differentiation and division. Activation of the wild type FGFR3 may occur via ligand independent dimerization of the over-expressed protein, increased expression of ligand or via differential splicing that generates a splice variant such as FGFR3c with the altered ligand specificity  stained slides were reviewed by two pathologists and the diagnosis was made as per the WHO 2016 criteria of urothelial tumors.th edition into pTa, pT1 and pT2 tumors.The staging was done in accordance with the TNM AJCC 8Inclusion criteriaMicroscopically proven cases of urothelial carcinomas including low grade non-invasive, high grade non-invasive, low grade invasive and high grade invasive.Exclusion criteriaUrothelial carcinoma arising from kidney and ureter;Bladder malignancies other than urothelial carcinoma.Recurrence was considered as cases which had visible tumor on follow up cystoscopy and were confirmed by the subsequent histopathological evaluation.pTa tumors (non-invading lamina propria) and pT1 tumors (invading into lamina propria) were categorized as non-muscle-invasive tumors and pT2(invading detrusor muscle) were categorized as muscle-invasive tumors due to the difference in different treatment modalities.The non-muscle-invasive tumors were treated with chemotherapy and intravesical BCG therapy. One case of LG non-invasive urothelial carcinoma underwent radical cystectomy due to failure of BCG therapy.The cases with muscle invasion underwent radical cystectomy, however, the patients who were found to be unfit for the surgery in this category underwent TURBT and chemoradiotherapy.Paraffin blocks made after routine processing were cut as 3 microns sections and were stained with H & E for the routine morphology. Tumor grading was performed based on the architectural and cytological features. 2a, Source: mouse, Immunogen: amino acids 25-124 of FGFR3 of human origin, Santa Cruz Biotechnology, USA) was conducted on the estimated sample size of 55 cases of histopathologically proven urothelial carcinoma cases. The IHC was performed on 0.1% poly-L-Lysine coated slides, which were then kept in the incubator for 30 minutes at 60°C. The slides were placed in citrate buffer at pH of 6.0. Heat induced antigen retrieval was done by pressure cooker with an operating pressure of 103kpa/115 at 120°C, then, blocking was done by 3% hydrogen peroxide. The antibody was used in a dilution of 1:50 and incubated overnight.Blocks with the section containing the tumor and adjacent normal epithelium were chosen for immunohistochemical study. This Immuno-histochemical study of FGFR3 .All the slides were examined and scored according to the Q score.Q score (6):A semi-quantitative scoring system was adopted: 0, all tumor cells negative; 1, faint but detectable positivity in some or all cells; 2, weak but extensive positivity; 3, strong positivity. Percentage staining score was graded as 0 to 4.Q score = intensity × percentage staining Q score of 0 and 1 were taken as negative result and 2 to 12 as positive result.4. However only one case of low grade non-invasive carcinoma showed nuclear positivity, which was an exception in our study, therefore it was not included in the statistical analysis. FGFR3 expression was observed in the cytoplasm and nucleusThe statistical analysis was done on the data collected using the “SPSS Version 11” statistical program. Pearson Chi-square test was used to determine significant clinicopathological differences between FGFR3 expression in positive and negative tumors. Differences were considered statistically significant when P-value was < 0.05. Patients’ characteristics, treatment and recurrenceThe study comprised of 55 patients, of whom low grade non-invasive tumors were diagnosed in 24 (43.6%) ones. However, in our study no low grade invasive tumor was found. High grade invasive tumors accounted for 22 (40%) of all the cases, whereas high grade non-invasive were found to be 9 (16.4%).The patients were followed up for 5 to 36 months, mean follow-up period was 24 months. In our study, eight HG invasive and one LG non-invasive tumors underwent radical cystectomy. Of the remaining 46 cases, 93.3 % (14/15) HG invasive recurred. Amongst HG non-invasive cases, 62.5% (5/8) recurred. The recurrence was documented in 47.8 % (11/23) of LG non-invasive tumors. FGFR3 expressionIHC expression of FGFR3 antibody in HG invasive urothelial carcinoma was positive in 18% (4/22) cases. The Q score in HG invasive tumors ranged from 0 to 4, average was 0.72 ±1.20. In HG non-invasive urothelial carcinomas the positivity was seen in 66.7% (6/9) of cases. High grade non-invasive tumors had a range of Q score from 1 to 6, with an average of 3.11 ± 1.76.The highest positivity was seen in LG non-invasive urothelial carcinoma 82.6% (19/23) of tumors. LG non-invasive tumors had a Q score ranging from 1 to 12 with an average of 5.86 ± 4.28. One case of LG non-invasive urothelial carcinoma had nuclear positivity for FGFR3.FGFR3 expression with grade and stageIn non-invasive carcinoma FGFR3 expression was present in 78.1 % (25/32) whereas, it was negative in21.9%  of tumors, while 18 or 81.8% were negative.P<0.05).The P-value was significant (P<0.05)FGFR3 expression in low grade tumors was positive in 82.6 % (19/23) and negative in 17.4% (4/23) of the cases. And 67.7 % (21/31) of high grade tumor cases were found to be negative whereas 32.3% (10/31) were positive for FGFR3. The P-value was found to be significant (FGFR3 expression in recurred casesFGFR3 was expressed in 14.3% (2/14) of HG invasive tumors which recurred. In this category 85.7% of the cases were negative. HG non-invasive tumors were positive in 80% (4/5) of the cases, whereas 20% were negative for FGFR3.LG non-invasive tumors were positive for FGFR3 in 72.7% (8/11) of the cases, whereas 27.3% (3/11) were negative. This was significant with a P-value of <0.05.9. In a study conducted on 45 patients younger than 30 years Huang et al., observed that patients aged 25 years or younger were less likely to experience tumor recurrence and expressed more proportion of the negative pattern of FGFR3 protein .In the present study there was a significant association between FGFR3 expression and the stage  was found to be 18.2% of cases. This showed a significant association between the stage and FGFR3 expression with P-value< 0.05. Our value was in concordance with a study by Bodoor et al  on 130 pGuancial et al., in 2015 studied 231 primary muscle-invasive tumors and found a positivity of 29% by IHC . On the In our study, positivity and negativity for the low grade tumors was assessed to be 82.6% and 17.4% cases, respectively. The 81.3% of low grade tumors were positive as reported by a Korean study .Young-HeeMaeng et al., reported 47.8% of high grade tumors to be positive for FGFR3  ,22, 23 ,Poyet et al., in 2015 reported that patients with tumors expressing FGFR3 confirmed by IHC had a significantly increased disease specific survival as compared to the negative expression. High grade neoplasms in their study showed a trend of better disease specific survival but it was not statistically significant .In the current study, invasive tumors which recurred were positive for FGFR3 in 14.3% of the cases. This was found to be statistically significant (In the cases of high grade invasive carcinoma which underwent radical cystectomy only one out of nine cases showed positivity for FGFR3.Guancial et al., did not find any association between muscle-invasive urothelial carcinoma and overall survival . Turo etOne of the cases in our study was diagnosed to have low grade non-invasive carcinoma who underwent radical cystectomy. Clinically and radiologically he had extensive involvement of the bladder mucosa by papillary neoplasm, with histopathological extension into the prostatic ducts. This case had an interesting FGFR3 staining pattern of nuclear positivity.Nuclear positivity of FGFR3 has not been studied extensively due to the small proportion of such staining in other studies. In the study done by Rotterud et al., in 2007 , they coThe FGFR3 expression is seen in urothelial carcinoma. It is high in low grade, non-invasive tumors, and tumors showing recurrences which are non-invasive. The targeted therapy for FGFR3 may be used as one of the modes of treatment for urothelial carcinoma. It can also be used as a marker to determine the grade in difficult cases and the risk of recurrence.


FSWs), intensified community mobilization activities in three sites to increase protective behaviours and utilization of clinical services. We compare indicators among FSWs at the beginning and after implementation.‘Sisters with a Voice’, Zimbabwe's nationally scaled comprehensive programme for female sex workers  in 2015, routine clinical data from 2010 to 2015, and two respondent driven sampling surveys in 2011 and 2015, in which participants completed an interviewer‐administered questionnaire and provided a finger prick blood sample for FSWs were recruited from the three sites in 2011 and 915 in 2015. Using logistic regression to adjust for socio‐demographic differences, we found higher estimates of the proportion of HIV‐positive FSWs and HIV‐positive FSWs who knew their status and reported being on ART in Mutare and Victoria Falls in 2015 compared to 2011. Reported condom use with clients did not differ by year; however, condom use with regular partners was higher in 2015 in Mutare and Hwange. Reported HIV testing in the last six months among HIV‐negative FSWs was higher in 2015 across sites: for instance, in Victoria Falls it was 13.4% (95% CI 8.7% to 19.9%) in 2011 and 80.8% (95% CI 74.0 to 87.7) in 2015. FSWs described positive perceptions of the Sisters programme, ease of engaging with health services, and improved solidarity among peers. Programme data showed increases in service use by 2015 across all sites.870 HIV care engagement indicators were observed among FSWs in two sites and in testing and prevention indicators across the three sites after implementation of an intensified community mobilization intervention. Engagement with services for FSWs is critical for countries to reach 90‐90‐90 targets.Improvements in key  We explore whether observed differences might be linked to the delivery of intensified community mobilization.2We draw data from three sources to inform the conclusions; Respondent Driven Sampling (RDS) surveys conducted in 2011 2.1Women were eligible for inclusion if they were aged ≥18 years, working at the study site and reported exchanging sex for money in the past 30 days.2.2The study was conducted in Mutare, a small city bordering Mozambique; Victoria Falls, a tourist town bordering Zambia; and Hwange, the location of a large colliery. The 2011 survey was conducted eight months after initiation of the intensified community mobilization, while the 2015 round took place 54 months after implementation.2.3In 2010, we intensified community mobilization in Mutare, Hwange and Victoria Falls, providing peer‐delivered activities biweekly instead of monthly. We hired additional peer educators, who brought FSWs together in participatory workshops to build solidarity and reduce competition. We further trained public sector health workers to be more “sex worker friendly” through a three‐day workshop, and five‐day attachment allowing them to shadow nurses at the Sisters’ clinics, and monthly meetings with Sisters clinic staff and peer educators. The aim of intensified community mobilization was to foster an enabling environment for sex workers to adopt protective behaviours and increase their use of health services. In 2014, specific activities designed to engage younger women were introduced 2.4In the absence of a sampling frame, we used Respondent Driven Sampling (RDS) to recruit women. While there is debate on the extent to which RDS achieves representativeness First, we conducted rapid ethnographic mapping to inform the feasibility and design of the RDS survey, including selection of initial recruiters (seeds) 2.5A questionnaire was developed in English, translated into Shona and Ndebele, and pilot tested. Responses were entered directly into a computer‐assisted survey instrument (QDS™ Nova research Company in 2011 and Open Data Kit in 2015). Data were collected anonymously, covering socio‐demographic and economic variables, sexual behaviour, mental and physical health, history of STIs, sexual and social networks, social capital, utilization of services including HIV testing, ART, PMTCT and family planning.2.6® HIV Microelisa Systems BioMerieux, Inc, Durham NC 27704. Discrepant results were resolved using Western blot. Referral for HIV testing was made freely available in the Sisters clinics.Finger prick blood samples were collected onto filter paper by a nurse and transported to the National Microbiology Reference laboratory in Harare. They were tested for HIV‐1 in series using AniLabsystems EIA kit  with specimens testing positive re‐tested using Vironostika2.7We conducted semi‐structured interviews in 2015 with all study seeds . Interviews explored FSWs’ perceptions of their work, access to and quality of health services, and their experiences of community networks and support. All interviews were conducted in Shona or Ndebele. Audio‐recorded data were transcribed and translated verbatim into English, and entered into NVivo 8  for coding. For this paper, we extracted data referring to knowledge, participation, and perceptions of the intensified community mobilization.Following data familiarization, the third author conducted “broad brush” thematic coding on perceptions of available health services, use of services, and facilitators and barriers to accessing both public service and targeted Sisters clinics; this was followed by more detailed inductive coding. Analysis of qualitative data was conducted specifically to complement and help explain quantitative findings on differences over time in uptake of Sisters clinical and community services, in relation to the “intensified” components, and in comparison to other available healthcare.2.8Programme data for 2010 to 2015 was drawn from the Sisters’ data collection system which collects client data electronically in real time. Nurses enter data into the system using a tablet at each client visit. A unique identifier is allocated and demographic data are recorded during the first visit. At the first and all subsequent visits clinical data including presenting problems, services offered and diagnoses are collected.2.9Key indicators assessed were drawn from the RDS surveys, namely: HIV prevalence, knowledge of HIV status among HIV‐positive FSWs and testing in the last 6 months amongst HIV‐negative FSWs, engagement with care and ART use among HIV‐positive FSWs, and reported condom use with clients and regular partners. We also investigated self‐reported service uptake including contact with peer educators, visits to the clinic, testing behaviour and perceived social cohesion.We classified individuals who were HIV positive as knowing their status if they tested positive on the survey and self‐reported that their last HIV test was positive, and on ART if this was self‐reported, or HIV‐negative if they tested negative for HIV and reported that they had tested negative within the last 6 months.2.10We describe the prevalence of programme engagement and key HIV status, prevention and care indicators in 2011 and 2015, accounting for the RDS design using RDS‐I weighting While we cannot attribute changes in HIV prevention and care indicators to the Sisters programme, we are interested in assessing whether differences in indicators between 2011 and 2015 suggest improvements in engagement with HIV prevention and care services. To determine evidence of bias in RDS estimates at each time‐point due to non‐convergence of sample waves (dependence on seed characteristics) we assessed the cumulative estimate over sample waves , the UCL Ethics Committee, and the London School of Hygiene and Tropical Medicine Ethics Committee.FSWs were consulted on intervention design and peer educators were actively involved throughout its implementation.33.1In 2015, 913 women were included in analysis: 407 in Mutare, 255 in Hwange and 251 in Victoria Falls compared to 836 women in 2011: 370 in Mutare, 237 in Hwange and 229 in Victoria Falls. Following the seeds, there were five additional recruitment waves in all sites in 2011 and six in 2015. Appendix 3.2FSWs’ median age in both years was 33. The age distribution remained similar over time in Mutare and Hwange, however the proportion of those younger than 25 years changed from 39.5% (95% CI 30.3 to 48.7) in 2011 to 16.3% (95% CI 12.1 to 20.5) in 2015 in Hwange.More women reported no education or incomplete primary education in 2011 than 2015 , 31.6% (95% CI 26.4% to 36.7%), 29.8% (95% CI 23.7% to 35.9%) FSWs reported having visited the Sisters clinic in the last 12 months in Hwange, Mutare and Victoria Falls respectively. In 2015, the time period over which clinic attendance was assessed was reduced to the previous 6 months and was 77.9% (95% CI 69.1% to 86.7%), 47.0% (95% CI 40.9% to 53.2%) and 50.1% (95% CI 42.4% to 57.9%) in Hwange, Mutare and Victoria Falls respectively.Contact with a peer educator in the last 12 months was reported by 32.9% (95% CI 26.6% to 39.1%), 31.1% (95% CI 27.8% to 38.4%) and 36.9% (95% CI 29.9% to 43.8%) of women in 2011. In 2015 the time period for contact with peer educators was changed from last 12 to last 6 months, and the proportion reporting contact was perhaps as a consequence reduced to 30.3% (95% CI 24.5% to 36.1%), 20.4% (95% CI 16.7% to 24.0%) and 26.1% (95% CI 21.0% to 31.2%) in Hwange, Mutare and Victoria Falls. The proportion of women who reported receiving condoms from the Sisters clinic was higher in 2015 than in 2011 in all sites. A lower proportion of women reported receiving condoms from peer educators in Hwange (Table 3.4p = 0.022) in 2015 compared to 2011 in Hwange . Evidence of an increase in prevalence in Mutare reduced significantly once adjusted  , a pattern similar in Victoria Falls with 69.6% (95% CI 61.7 to 76.7) HIV‐positive in 2011 and 62.1% (95% CI 55.3 to 68.7) in 2015. In Mutare, HIV prevalence was observed to be higher at 63.7% (95% CI 58.2% to 69.2%) in 2015, to 50.6% (95% CI 43.5% to 58.6%) in 2011  and Mutare , but not in Hwange.There was evidence of an increase in the odds that HIV‐positive women knew their status in Victoria Falls (aOR = 2.26 p = 0.035) and in Mutare . While a similar, though smaller, effect was seen in Hwange in the unadjusted results, there was no longer evidence for this effect  after adjustment.There was strong evidence that HIV‐positive FSWs who reported being aware of their status were more likely to report being on ART in 2015 in Victoria Falls  to 78.1% (95% CI 71.0 to 85.2), in Mutare from 30.3% (95% CI 23.2% to 38.6%) to 78.6% (95% CI 71.7% to 81.5%), and in Victoria Falls from 13.4% (95% CI 8.7% to 19.9%) to 80.8% (95% CI 74.0 to 87.7). This effect remained even after adjustment .There was little evidence of a difference in consistent condom use with clients in the past month in 2011 and 2015, except in Mutare, where an increase was observed in 2015 after adjustment , but there was little evidence of a difference in Victoria Falls.In Mutare and Hwange, condom use with regular partners was higher in 2015 compared to 2011, .Appendix 1. RDS Diagnostics in 2011 and 2015.Appendix 2. Respondent Driven Sampling Questionnaire 2015 in word format.Click here for additional data file.


A total of 61 subway workers, including 26, 23, and 12 subway station managers, maintenance engineers, and train drivers, respectively, were investigated in 2018. Real-time measurements of airborne PM2.5 and BC were simultaneously conducted around the breathing zones of workers. Maintenance engineers had the highest average levels of exposure to both PM2.5 and BC , followed by train drivers  and subway station managers . In terms of the relationship between mass concentrations of PM2.5 and BC, train drivers demonstrated the strongest correlation (R = 0.72), indicating that the proportion of BC contained in PM2.5 is relatively steady. The average proportion of BC in PM2.5 among maintenance engineers (13.0%) was higher than that among train drivers (9.4%) and subway station managers (6.4%). Univariate and mixed effect multiple analyses demonstrated the type of task and worksite to be significant factors affecting exposure levels in maintenance engineers and subway station managers. The use of diesel engine motorcars in tunnel maintenance was found to be a key contributor to PM2.5 and BC exposure levels among subway workers.This study aimed to assess the characteristics of exposure to both PM Recentl quality .2.5 and PM1.0) deserve particular attention as these particles may penetrate deep into the bronchiolar areas of the lung, causing various health hazards [Many studies have been conducted worldwide, including in the Republic of Korea, regarding the harmful substances and human health risks in the environment of the subway systems . One of  hazards . The PM  hazards .2.5 have not been simultaneously evaluated in these workers.Numerous studies have evaluated DEE exposures in various jobs using its primary surrogates , such as black carbon (BC), elemental carbon, total carbon, respirable particulate matter, and nitrogen dioxide. Studies have found that DEE exposures among underground miners and tunnel construction workers are markedly higher than those in aboveground truck/bus drivers, truck/bus garage mechanics, fire fighters, and heavy equipment operators ,11,12,13The main sources of environmental BC are the incomplete combustion of fossil-based fuels and the burning of biomass on the Earth’s surface . BC from2.5 and BC. It also aimed to evaluate the job- and subway-related environmental factors influencing PM2.5 and BC exposures and to evaluate the relationship between exposure to PM2.5 and BC.According to the Korea Workers’ Compensation and Welfare Service, 10 cases of respiratory diseases  were reported from 2007 to 2012 as work-related diseases among subway workers . HoweverSubway workers in the Republic of Korea may be categorized into three types based on their jobs: maintenance engineers, subway station managers, and train drivers. Maintenance engineers may be further classified based on the various subway facilities that they manage, including equipment, machines, railways, and tunnels, among others. Exposure characteristics of hazardous agents among maintenance engineers may vary depending on the tasks they perform. The categories of maintenance work that this study focused on included the repair and maintenance of underground tunnels at night, after the completion of routine daily operations. These tasks are performed using diesel vehicles. Subway station managers mostly stay in offices located near ticket boxes and regularly patrol the entire length of the subway stations, including the platforms. They may be exposed to hazardous agents generated in subway stations that may vary depending on the location of the subway. Two shift work cycles operate between 5 a.m. to around midnight, from the beginning to the end of daily subway operations. Train drivers operate the trains according to irregular shift schedules, known as train diagrams. They work from small cabin rooms during the entire duration of their duty hours. Therefore, the characteristics of exposure to hazardous agents depends on the various facility characteristics of several stations along the subway route.A total of 61 subway workers, including 26 subway station managers, 23 maintenance engineers, and 12 train drivers working on the Seoul, Bundang, and Incheon city lines, were investigated between April and September 2018. The subway workers (n = 61) with shifts scheduled when the measurements were being conducted were all selected to participate in the study. The basic characteristics of the subway lines surveyed in this study are summarized in 2.5 and BC concentrations were both simultaneously monitored during working hours to capture differences in time-activity patterns, based on jobs and locations of on-duty workers. On the sampling day, workers were asked to carry two samplers for each PM2.5 and BC, equipped with a tube fitted near the breathing zone to estimate inhalational exposures. Simultaneously, a time-activity diary was completed by workers in a provided form. Information registered in the time-activity diary included the main tasks, the beginning and ending times for each job, and the locations they worked at or visited while on duty. The accuracy of information was verified by consulting the logged measurement levels.Real-time airborne PM2.5 concentrations were measured using a SidePak personal aerosol monitor  fitted with a 2.5 μm impactor. The impactor was cleaned and greased prior to each use and was set to an airflow rate of 1.7 L/min. Prior to each measurement with the included high efficiency particulate air filter, the instrument was calibrated to zero. SidePak monitors are light-scattering laser photometers with a resolution of 1 µg/m3. The data obtained from the SidePak AM520 m were multiplied by a photometric calibration factor (PCF) of 0.38. The purpose of the PCF is to compensate when measuring for aerosols that have different photometric properties than those used during factory calibration. The manufacturer recommended that a PCF of 0.38 be used for the ambient aerosols present in the urban environment [PMironment . All Sid3. The detection limit of the aethalometer was 1 ng/m3. The manufacturer’s default specific attenuation coefficient of 16.6 m2/g was used. To enhance the sensitivity, the air sampling rate was set at 0.15 L/min. Real-time measurements were recorded every minute. Since the instrument was small and portable (280 g), it was possible to use it to directly monitor the daily personal exposure to BC while workers moved through different zones of activity with varying BC concentrations. The filter strips were replaced prior to each sampling to minimize the filter loading effect. To test the precision of monitoring, the results from four micro-aethalometers were intercompared.The BC levels were monitored using an aethalometer . This instrument measures the intensity of light (880 nm wavelength) transmitted through a T60 Teflon-coated glass fiber and reports BC concentrations in ng/m2.5 and BC were simultaneously recorded for 1 min each during working hours. The data were downloaded soon after monitoring to minimize data handling errors or recall bias. The three data values of “0” in the BC measurements were changed to half of the detection limit of 1 ng/m3, as previously described [2.5 and BC were found to have a right-skewed distribution, indicating frequent high-level exposures. Therefore, the data were natural log-transformed for statistical analyses to better fit the normal distribution. The data were presented as descriptive statistics, including the arithmetic mean (AM), standard deviation (SD), geometric mean (GM), geometric standard deviation (GSD), minimum (Min) value, and maximum (Max) value. To identify work activities and potential environmental risk factors that contribute to exposure, all PM2.5 and BC records were classified according to the following several categories: (i) temporal factors: type of day, time of day, and rush hour; (ii) subway environmental factors: subway line, location of subway (underground or at ground level); and (iii) job: subway station manager, maintenance engineer, and train driver.Real-time measurements of both PMescribed . A total2.5 and BC exposure levels according to categorized jobs, tasks, and environmental factors; correlations between repeated measurements at the same working or visited locations over time were modeled by a first-order autoregressive covariance structure with random effects. Sequential likelihood ratio tests (LRTs) were conducted to assess: (1) whether a linear mixed model was preferred for analyses over a linear regression model without random effects, and (2) the impact of potential risk factors on PM2.5 and BC exposures while accounting for subway features, such as line, on the basis of the test results of a random effect. For each model, residuals were thoroughly assessed to check the model’s assumptions, such as linearity and normality. The level of significance was set at 0.05 and all statistical analyses were performed using the R version 3.5.1.  software package.A linear mixed model was used to compare average natural logarithm-transformed PM2.5 and BC according to job are presented in The distribution of levels of exposure to PM2.5 and BC levels were 50.5 (range: 1.9–2774) µg/m3 and 4.3 (range: 0.0005–283.1) µg/m3, respectively. The exposure levels of both PM2.5 and BC were significantly different among the types of jobs (p < 0.0001) (The average PM 0.0001) .2.5  and BC   and BC . The GM of the concentrations of PM2.5 (54.9 µg/m3) and BC (4.9 µg/m3) was the highest among train drivers, with the lowest variation in PM2.5 (3.5–200.9 µg/m3).Maintenance engineers demonstrated the highest AM concentrations and the largest variations in both PM3 µg/m3) . Subway 2.5 and BC. In subway station managers, the time variable was also found to contribute significantly to exposure levels of PM2.5 and BC (p < 0.001)  .2.5 and BC (p < 0.01)  and BC (p = 0.287) exposure among train drivers.Among maintenance engineers and subway station managers, the linear mixed effects model also demonstrated task type to be the most significant factor associated with the exposure levels of PM < 0.01) . In main2.5 and BC on the log scale by job. The correlation coefficients between jobs were calculated after conducting linear regression among 61 subjects. Train drivers demonstrated the strongest correlation (R = 0.72), followed by maintenance engineers (R = 0.61) and subway station managers (R = 0.4).2.5 in the 61 subjects ranged from 2.5% to 30.2% (2.5 among maintenance engineers was significantly higher than that in the other jobs (maintenance engineers vs. subway station managers vs. train drivers: 13.0% vs. 6.4% vs. 9.4%).The proportion of BC contained in PMto 30.2% . The ave2.5 and BC from data observed in representative cases, with the peak exposures by jobs. Several peaks of relatively high levels were generally observed in short periods of time during the entire work duration.2.5 and BC were higher in maintenance engineers than in the other workers. In particular, the PM2.5 and BC concentrations increased more than 100-fold during grinding of rails outside the diesel engine motorcar. As demonstrated in 2.5 (177.0 µg/m3) and BC (75.5 µg/m3) in subway station managers were observed during platform patrolling. As depicted in 2.5 and BC. 2.5 and BC for each job, irrespective of tasks.As seen in 2.5 and BC among subway workers and explored the relationships between them according to jobs, tasks, locations, and time variables. Several factors were found to significantly influence the levels of exposure to PM2.5 and BC.This study assessed daily integrated levels of inhalational exposures to PM2.5 and BC and with the relationship between PM2.5 and BC. Maintenance engineers demonstrated the highest levels of exposure to both PM2.5 and BC, followed by train drivers and subway station managers , indicating that the proportion of BC contained in PM2.5 is relatively steady (2.5 among maintenance engineers (13.0%) was higher than that among train drivers (9.4%) and subway station managers (6.4%). When the proportions of BC were monitored across 24 sites of EUROAIRNET in Europe; it was found to contribute to 5%–10% of PM2.5 and to lower proportions of PM with an aerodynamic diameter smaller than 10 μm (PM10) [2.5 was 17%; this was similar to our results, which demonstrated a relative contribution of 16.5% among maintenance engineers who worked near diesel engine motor cars during rail grinding (Type of job was found to be closely associated with levels of exposure to both PMmanagers . The proree jobs . In termy steady . The avem (PM10) . In partgrinding .3 (3) were observed to be similar to the levels of exposure to PM2.5 (62.0 µg/m3) among all workers. These results demonstrate that maintenance engineers who maintain subway tunnels are generally exposed to high levels of DEE, with consequent high exposure to ultra-fine PM and BC. DEE contains respirable particles, of which 80%–95% are fine and measure <2.5 μm [2.5 may also be used to determine DEE exposures [2.5 among maintenance engineers. This result is in agreement with a previous study conducted in New York City (NYC) [In general, maintenance engineers use diesel engine motorcars while working inside tunnels. Since this maintenance work takes place at night when the electric power is switched off, the maintenance vehicle uses its own power; therefore, the diesel engines run throughout the duration of work. Our findings suggest that while working inside or close to diesel motorcars, maintenance engineers may be exposed to high levels of BC, exceeding 200 µg/m3 . Interes <2.5 μm ,29. In t <2.5 μm ,31; PM2.xposures ,33,34. T2.5 or BC measurements. Readers should note that for a given analysis, both linear mixed and linear regression models had the same set of predictors, but differed only by a random effect. For the example of train drivers’ exposure to PM2.5 in 2.5 was evaluated with another LRT in the presence of line as a covariate. Although data were not shown, no remarkable pattern was observed in the residual assessment of linear mixed models, indicating that model assumptions seemed to be satisfied.A linear mixed model was employed as the main statistical analytic tool for this study; statistical tests for both random  and fixed effects (subsequent test) were conducted for LRTs . For all2.5 and BC exposure levels according to job, tasks, worksites, and time provide accurate estimates of daily exposure levels. This study assessed the exposure of individual subway workers, so we did not evaluate air quality by sampling fixed areas at the platform or station hall. Therefore, workers’ job characteristics were more important factors in understanding their exposure levels than the features of the subway line, such as the year it opened or the number of stations. Both univariate and linear mixed effect multiple analyses revealed tasks and worksites to be significant factors affecting exposure levels among maintenance engineers and subway station managers  did not encompass all the seasons of the year; this may also reduce the generalizability of our findings. Our data in the summer included personal PM2.5 and BC levels measured between April and September; this may have underestimated the daily BC exposure levels in the colder months, when reinforced heating and reduced ventilation are likely to increase exposure. Fromme et al reported that the concentrations of benzo-a-pyrene and elemental carbon monitored in the winter are three to four times higher than those in the summer, corresponding to the changes in ambient air concentrations in cars and subway transportation systems [This study has several limitations. A major drawback lies in the uncertainty of whether the BC exposure levels among subway workers in this cohort are representative of all subway systems. These findings may not be generalizable to other subway environments with different workplace characteristics and physical environments in and around the subway. Since the 61 subway workers surveyed were not randomly selected, the PM systems .2.5 and BC exposures among subway workers. To our knowledge, this study is the first to simultaneously assess the levels of exposure to both PM2.5 and BC among subway workers by using synchronous real-time personal monitoring.This study has certain strengths. It identified job type and use of diesel engine vehicles for tunnel maintenance to be potential risk factors for PM2.5 and BC exposure levels for subway workers were significantly different according to the type of job, the tasks conducted, and the worksite. Maintenance engineers had the highest exposure to both PM2.5 and BC, followed by train drivers, then subway station managers. In terms of the tasks and worksite, maintenance engineers and subway station managers showed the highest exposure levels during rail grinding in tunnels with diesel engine motorcars and patrolling platforms close to tunnels, respectively. This study also shows that the use of diesel engine motorcars during tunnel maintenance is a key contributor to PM2.5 and BC exposures among subway workers. Therefore, proactive measures, including installing DPFs on diesel engine maintenance vehicles in tunnels, are urgently needed to reduce subway workers’ exposure to both PM2.5 and BC. Further studies on other subway systems are needed to validate our findings.In conclusion, both the PM


HTT). In China, HD is considered to have a low prevalence. The goal of this study was to describe the clinical characteristic and genetic profiles of HD in a Chinese cohort. A total of 322 individuals with expanded CAG repeats were consecutively recruited from the neurologic clinics of three medical centers in Southeastern China between 2008 and 2018. Among them, 80 were pre-symptomatic mutation carriers and 242 were symptomatic patients. The mean age at onset (AAO), defined here as the age at motor symptom onset, of the 242 manifest HD individuals was 40.3 ± 11.9 years and the mean CAG repeat length was 46.1 ± 7.5 in the group of symptomatic patients. Initial symptoms were abnormal movements in 88.8% of the patients with psychiatric symptoms in 6.2%, cognitive impairment in 3.3% and others in 1.7%. The AAO of motor was negatively correlated with the CAG repeat length in an exponential regression analysis . Analysis of 46 parent-child pairs showed that the CAG repeat length was longer in the offspring group (45.8 ±7.6) than in the parent group (43.8 ±3.0) (p=0.005). Overall, this study provides clinical and genetic profiles in a cohort of Chinese patients with HD, which should contribute to a better understanding of this disorder.Huntington’s disease (HD) is an autosomal dominant inherited neurodegenerative disorder caused by CAG triplet repeats expansion in exon 1 of the Huntingtin gene ( HTT) [ HTT gene contains a sequence of 6-26 CAG repeats. Individuals who inherit an expanded CAG repeat of 40 or more will manifest the disease with a complete penetrance, whereas those who inherited 36-39 CAG repeats may be affected with milder penetrance. Although the intermediate alleles (27-35 CAG repeats) are considered not to be in a pathogenic range, they are unstable alleles and may expand or contract during the germline transmission [Huntington’s disease (HD) is an autosomal dominant inherited neurodegenerative disorder characterized by movement disorder (i.e. chorea and dystonia), cognitive decline and psychiatric symptoms. HD is caused by CAG triplet repeats expansion in the exon 1 of the Huntingtin gene (HTT) . In geneHD prevalence is about 4-10 per 100,000 in the Caucasian populations but varies greatly between ethnic origins -7. RecenIn this study, we aim to provide a description of the clinical characteristics, genetic profile in a cohort of Han Chinese HD patients and gene carriers. We compared our findings with those reported in other ethnic populations around the world. These data are of great significance in guiding the clinical practice, especially in practical diagnostic process and genetic counselling. Moreover, the clinical and genetic studies of HD in different ethnic populations may provide new insights into this disorder.HTT genetic tests. Predictive tests were performed in relatives as they requested after appropriate genetic counsel. Pre-symptomatic mutation carriers refer to those who show no motor signs and no other subjective symptoms or clinical sign which would be typical for HD. Comprehensive demographic and clinical data, including medical and psychiatric history, HD family history, and current medications were collected from the participants. All participants signed the informed consent form, or if the participants were unable to provide consent, an authorized representative provided the consents on their behalf. The study was approved by local Ethics Committees  for medical research at three participating hospitals.A total of 322 individuals with expanded triplet repeats (80 pre-symptomatic mutation carriers and 242 manifest HD) from 238 families were consecutively recruited from the neurologic clinics of three medical centers  in China between February 2008 and March 2018. HD diagnosis was made by at least two senior neurologists according to patients’ clinical manifestations in the context of positive The age at onset (AAO) is defined by the age when motor signs or symptoms occur. Homozygous HD gene carriers refers to individuals with two expanded alleles. HTT gene was performed using the method previously reported [HTT (F: 5′ -CAGAGCCCCATT CATTGCC-3′ and R: 5′-TGAGGAAGCTGAGGA GGC-3′) were used to amplify the exon 1 in the CAG polymorphic region of the HTT gene. Polymerase chain reaction (PCR) amplicons were electrophoresed on a 1.5% agarose gel at 180V for twenty minutes to determine the primary HTT results. Then the length of CAG repeats was determined by Sanger sequencing.Genomic DNA was extracted from peripheral blood treated by ethylene diamine tetraacetic acid (EDTA). Genetic testing forreported . BrieflyDemographic, clinical characteristics and genetic profile were analyzed using descriptive statistics. The data distributions of AAO and CAG were assessed by Kolmogorov-Smirnov test. AAO was normally distributed yet the CAG was distributed with a skew. For comparison between two continuous variables, T tests, Wilcoxon tests or Mann-Whitney were used as appropriate. ANOVA was used for comparison between multi-group. Correlation was calculated by Pearson or Fisher exact Chi-Square when appropriate. Statistical analysis was conducted using SPSS 20.0. The p-value less than 0.05 was considered statistically significant.As shown in Reliable data on AAO were available in 242 HD patients. The mean motor AAO was 40.3 ± 11.9 (range 4-71) years  Fig. 2AFig. 2A. Among the 242 symptomatic gene carriers, 215 first presented with motor signs  and 27  presented with non-motor symptoms and developed motor disorder later. Chorea was the most frequent motor sign . Other types of motor symptoms included ataxia , gait instability , parkinsonism , tics , tremors  and dystonia . Eight patients  had cognitive impairment first, of whom 5 with memory decline and 3 with intellectual decline. Fifteen subjects  had psychiatric and behavioral symptoms, including agitation , depression  and psychosis . In addition, two patients had mixed psychiatric and cognitive impairment at onset and one patient had concurrent movement disorder and cognitive decline. Finally, one juvenile patient presented with seizure as initial symptom . Gender Data of 97 deceased HD patients from 238 families were analyzed to estimate the duration of disease. Seven of them died by accident (n=2), suicide (n=2), cerebral hemorrhage (n=2) or because of esophageal cancer . Hence, these seven patients were not included in the further analysis of disease duration.As shown in Fifteen had juvenile onset  with a mean CAG value of 67.0 repeats . Four caSeven patients developed symptoms at the age of 60 years or older  . Six hadThree homozygotes for elongated CAG repeats were found in our cohort . One wasData on CAG repeat numbers were available for 309 persons with HD. The three homozygotes mentioned above were excluded. The range of triplet repeats in the normal allele was 11-26 (mean 17.6 ± 1.6) while in the expanded allele, the range was 37-104 (mean 45.6 ± 6.9) .To analyze the CAG instability during the germline transmission, we selected 46 parent-child pairs from our cohort, including 23 father-child pairs from 23 families and 23 mother-child pairs from 20 families (as one mother had three children). The gender of the affected parent was an important factor affecting the CAG repeats instability. The mean CAG repeat number was 43.4 ± 3.3 in father group and 46.4 ± 10.4 in corresponding child group, expanding by 3.0 ± 7.9 repeats during father-child transmission. In mother-child transmission, the CAG expanded by 0.9 ± 2.6 repeats with the CAG repeat number of 44.3 ± 2.7 in the mother group and 45.2 ± 3.2 in the corresponding child group. There was a difference in the father-child transmission (p=0.014) but not in the mother-child transmission (p=0.145). By adding together, the CAG repeat length was more significantly longer in the offspring group (45.8 ± 7.6) than the parent group (43.8 ± 3.0) (p=0.005).HTT alleles showed similar proportion compared with the maternal transmitted ones.As shown in Correlations between the AAO, CAG and initial symptoms were assessed in 242 cases. To explore whether CAG repeat length and AAO differed with respect to initial symptoms, we divided patients into motor, cognitive and psychiatric groups. The CAG repeat number was larger in cognitive group (52.8 ± 11.6) than motor group (46.0 ± 7.4) (p=0.03) and psychiatric group (44.4 ± 6.3) (p=0.02). Accordingly, the AAO of cognitive group (25.1 ± 9.1 years) was earliest compared with motor group (40.5 ± 11.8 years) (p=0.0003) and psychiatric group (40.2 ± 11.1 years) (p=0.0035). This suggested that patients presented with cognitive impairment first had larger CAG number and earlier AAO. Further, we found chorea become more predominant with the increasement of AAO, from 26.7% (4/15) in JHD, 83.6% (184 in 220) in adult HD to 85.7% (6 in 7) in elder HD.2 = 0.74) using the exponential regression analysis . However, no correlation was found between CAG repeats and AAO in elder HD (p = 0.31). This indicated that the AAO of elder HD was not affected by the CAG repeat lengths.The AAO was inversely correlated with the expanded CAG repeat number (p<0.0001), and the CAG repeat lengths accounted for up to 74% of the variance in AAO  as well as the frequency of intermediate alleles was 2.5% (24/966) [Previous studies have suggested that the length of CAG repeats in normal HTT chromosomes is associated with the prevalence of HD in distinct populations. In a population with higher prevalence of HD, the size of normal CAG repeats was generally larger . Our stu(24/966) .The size of CAG triplet on expanded chromosomes was within a range of 38 to 104 (mean 46.1 ± 7.5) and the mean AAO was 40.3 ± 11.9 (range 4-71) years . MexicanThe negative correlation between CAG repeat length and AAO has been found in many studies in different populations and confirmed here again , 16. In We then analyzed various onset symptoms and found that the symptoms were quite diverse in juvenile onset HD. However, in adult HD and elder HD, the onset symptoms were relatively simple, usually including chorea-like symptoms. This suggests that larger CAG repeats  cause initial symptoms of great variety. Movement symptoms were the predominant initial symptoms among Chinese HD patients (89%), Korean patients (89%) , AmericaIn our cohort median duration of disease was 11 years, which is shorter than in the Leiden Roster, in which median survival in 800 HD patients was 16.2 (range 2-45) years from motor symptom onset . UnexpecFrequency of juvenile onset HD cases (AAO <21 years) and homozygous HD in other studies are 4%-10%-25 and 0In summary, this study presents the clinical characteristics and genetic profile of HD in the Han Chinese population. This constitutes a solid foundation for future clinical, genetic and therapeutic investigation of HD in China. However, there are some limitations of this study. First, the participants were recruited from three centers located at the Southeastern China, thus there might be some population bias. Second, because of the low prevalence of HD in China, many physicians or even general neurologists lack the knowledge for accurate diagnosis. As a result, the diagnosis of many patients is delayed, and the prevalence of HD and the duration of disease is likely to be underestimated. Further studies with additional patients are needed for a more comprehensive and accurate epidemiological survey of HD in Mainland China.www.aginganddisease.org/EN/10.14336/AD.2018.0911The Supplemenantry data can be found online at:


Importance: Prior studies evaluating opening pressure (OP) have mostly involved lumbar puncture (LP) for diagnosis of neurologic disease or small cohorts of healthy volunteers and therefore the normal OP is not well-defined.Objective: The goal of this study was to establish the normal range of OP in a community-based population using the Mayo Clinic Study of Aging (MCSA) and to evaluate factors that contribute to OP variability.Design: LP OP were obtained from participants aged 32–95 years between 11/1/07 and 10/1/17, as part of routine data collection for the MCSA, a longitudinal, population-based study of residents of Olmsted County, Minnesota.Setting: A longitudinal, population-based study of residents of Olmsted County, Minnesota.Participants: There were 639 participants  who underwent LP with recorded OP as part of the MCSA.Intervention: LP.Main Outcome(s) and Measure(s): LP OP was recorded along with variables that could possibly influence its variability, including age, body mass index (BMI), and obstructive sleep apnea (OSA).Results: Six hundred thirty-nine participants (56.8% men) underwent LP with recorded OP; average age was 71.0 years (SD 10.9) with a mean BMI of 28.0 (SD 4.6). Mean OP was 155.4 mmH2O (SD 41.9) with a 95% reference interval of 82–242 mmH2O . Increasing age was associated with lower OP (p < 0.001), while increasing BMI was associated with higher OP (p < 0.001). Twelve (2%) participants had OP ≥ 250 mmH2O; they were younger , had higher BMI , and were more likely to have OSA . Among the 79 participants with repeat LPs within 2.5 years, the coefficient of repeatability (CR) was 64.9. Ten (12.7%) had an OP difference ≥50 mmH2O between serial LPs.Conclusions and Relevance: This large population-based study showed that LP OP can vary significantly among individuals. Higher OPs were associated with higher BMI and younger age. In ae cutoff , 5–9, whe cutoff , 10, 11.Because LP carries some risk of adverse effects, current OP reference ranges are generated from LP performed for diagnosis of neurologic conditions or in small groups of healthy volunteers , 12, 13.The MCSA is a population-based study in Olmsted County, Minnesota. Details of the MCSA have been published previously . In brieStudy protocols were approved by the Mayo Clinic and Olmsted Medical Center Institutional Review Boards. All participants provided written informed consent to participate in the MCSA and for the LPs.LP was performed by trained teams according to a standardized protocol at Mayo Clinic . Participants were placed in the lateral decubitus position with legs in partial extension and a 3.5-inch 20G or 22G spinal needle with a three-way stopcock was inserted into the subarachnoid space. A 550-mm manometer was attached to the stopcock and the column of CSF fluid was allowed to equilibrate for 1–2 min before recording the OP. All procedures were performed in the middle of the morning.2O, Fisher's exact test was used for categorical variables and Wilcoxon rank sum test was used for continuous variables. The Kruskal-Wallis rank sum test was used to compare OP and the absolute differences between OP measurements across consecutive visits per participant amongst categorical variables. Linear regression models were used to evaluate associations of age, BMI, OSA, CAD, and HTN with the natural log of OP (due to the skewed nature of the data) and the absolute differences between OP measurements across consecutive visits per participant. A linear spline model was also fit to the natural log of OP to examine the change in opening pressure between patients <60 years old and ≥60 years old. For models addressing the natural log of OP, estimates of percent change in OP that correspond with the unit change in the independent variables (β) were estimated, using (eβ-1)*100, along with their 95% confidence intervals. Otherwise, linear estimates in the change of absolute differences in OP corresponding to the unit change in independent variables were estimated along with their 95% confidence intervals. Unadjusted and multivariable models adjusted for age and BMI were used to examine relative contributions of OSA, CAD, and HTN to OP variability. Logistic regression models were used to model the relationship between OSA and BMI with the predicted probability that OP would be ≥200 mmH20. Odds ratios [OR] and associated confidence intervals were estimated. A Bland-Altman plot was generated and the coefficient of repeatability (CR) was calculated to visually depict the variability in the differences between OP measurements from consecutive LP visits within 2.5 years of each other. All reported p-values are two-sided and evaluated at the 0.05 significance level.Continuous measures are conveyed as mean (standard deviation [SD]) or median , as specified. Categorical measures are summarized as number (percent). Patients' initial LP OP measurements were analyzed to identify an overall 95% reference interval of OPs and 95% reference intervals of OPs per BMI and age category. Ninety five percent reference intervals were determined by the 2.5th percentile as lower limit and the 97.5th percentile as the upper limit. To compare patient characteristics between patients with and without initial OP ≥ 200 or 250 mmH2 (SD: 4.6)  with a 95% reference interval of 82–242 mmH2O  who underwent LP with recorded OP as part of the MCSA. Average age was 71.0 years (SD: 10.9) with a mean BMI of 28.0 kg/mSD: 4.6) . Mean OP42 mmH2O . Only onn = 639) with those that did not , there was no significant difference in age  or BMI . Male gender was higher in the patients that elected to undergo a LP .When comparing the 17% MCSA participants who underwent LP (p < 0.001). The 442 (69.2%) patients with BMI <30 had a lower average OP  with 95% reference interval of 80.0–221.9 mmH2O than the 197 (30.8%) patients with BMI ≥30  with 95% reference interval of 101.4–260.0 mmH2O (p < 0.001) (BMI and OP were positively and moderately correlated with Pearson Correlation (R) = 0.5 . For eve< 0.001) .Stratifying further, patients with BMI <18.5 had the lowest average OP 108.7 (SD: 35.2), patients with BMI 18.5–25 had the second lowest average OP 130.7 (SD: 33.5), and patients with BMI 25–30 had the second largest average OP 152.5 (SD: 35.9). The largest difference appeared to be between patients with BMI <18.5 and BMI ≥30 .R = −0.45 (2O (SD 40.6) with a 95% reference interval of 115.2–260.0 mmH2O. In comparison, 535 patients 60 years or older had a lower average OP of 149.7 mmH2O (SD 39.7) with 95% reference interval of 80.7–231.3 mmH2O (p < 0.001) (p < 0.001) with R = −0.42, but there was no significant correlation in patients younger than 60  with R = 0.08 (The relationship between opening pressure and age was negative and linear with  = −0.45 . The 104< 0.001) , 5. UsinR = 0.08 . Howeverp < 0.001). In this cohort, there was no significant interaction or dependency between age and BMI . Stratifying the sample by age revealed that the association of BMI with OP within patients 60 years and older  was similar to the effect of BMI in patients 60 years or younger . Furthermore, BMI remained associated with an increase in OP for both patients younger (R = 0.48) and older than 60 (R = 0.51). When adjusting for BMI, older age remained associated with a decrease in OP in patients 60 years or older (β′ = −9.99% [95% CI: −12.3 to −7.62%]) and not associated with OP in patients younger than 60 (β′ = 1.61% [95% CI: −4.54 to 8.16%]).When adjusting OP for age and BMI, both remained significantly associated with OP for the full cohort. For every five unit increase in BMI, OP is expected to increase by 13.6% [95% CI: 11.4–15.8%], and for every 10 year increase in age, OP is expected to decrease by 8.8% [95% CI: 7.3–10.2%] (p = 0.012). When adjusting for BMI and age, the percent increase of OP in patients with OSA was no longer significant . Patients with CAD had lower median OP than those without , but this was not significant after adjusting for BMI and age . Patients with HTN had lower median OP , but this was no longer significant after adjusting for BMI and age .Opening pressure was not associated with HLD, DM, headache, depression, anxiety, needle gauge, or sex . Patient2O. They were younger  and had higher BMI . More of the higher OP patients had OSA  and depression . Fewer had headaches , CAD , or HTN . In logistic regression of OP ≥200 mmH2O, both BMI  and OSA  were significant when included in the same model . As such, OSA may contribute to elevated OP independent of BMI at higher OP since the interaction between the two measures was non-significant (p = 0.12).There were 101 (15.8%) patients with initial OP ≥200 mmH2O. They were younger  and had higher BMI . A majority of them had OSA . None of the other variables were statistically significant in this small subset of the cohort. Only 1 (8.3%) had headaches, which was not statistically different from the rest of the cohort (p = 0.31). None of the patients with elevated OP were documented to have papilledema on their ophthalmology or optometry examinations, which were done within 5 years of the LP.There were 12 (2.0%) patients with initial OP ≥250 mmH2O. The coefficient of repeatability (CR) between serial LP OPs was 64.9. Ten of 79 (12.7%) had an absolute OP difference ≥50 mmH2O. Two of 79 patients who had an initial OP ≥250 mmH2O had subsequent LPs with OPs < 250 mmH2O, and one patient of 79 had an initial OP <250 and subsequent LPs with OPs ≥250 mmH2O.There were 79 patients with two LPs performed within 2.5 years. The differences between the first and second LP OP are shown in the Bland Altman plot . The avep = 0.009). For every five unit increase in BMI, the absolute change in OP between the first and second LP visit increased by 7.1 mmH2O. None of the other variables examined influenced the variability of serial LPs, including age and OSA.Among the patients with repeat LPs, baseline BMI was positively associated with the absolute difference in OPs , which maintained significance when factoring in BMI. This suggests that OSA may raise OP above the traditional normal range even in the absence of neurologic disease.It has been speculated that OSA may be the cause of elevated intracranial pressure in some individuals with higher BMI. Our study showed a correlation between OP and OSA, but this correlation was lost when adjusted for BMI in the overall cohort. Other recent studies have not found increased incidence of papilledema in patients with OSA or of OSA in patients with IIH –21. AmonIn addition to BMI, the other variable that influenced OP was age, which was inversely correlated. Similar to our findings among participants from the MCSA, Fleischman and colleagues found that OP decreased in older age when they retrospectively evaluated more than 12,000 LPs performed primarily for diagnostic purposes . They fo2O between serial measurements. The overall CR is 64.9 mmH2O, which represents where the absolute difference between consecutive OP measurements are expected to lie with a probability of 95%. A difference of 64.9 mmH2O could alter the interpretation of normal vs. abnormal OP. Because Valsalva can increase OP by over 2-fold  and there was no difference in the LP OP between males and females, and therefore this bias unlikely changed the range of OP found in this study. In addition, there was no difference in age or BMI among MCSA participants that elected to undergo LP compared to those that did not. Lastly, the study included predominantly white patients because of the demographics of Olmsted County, Minnesota, and thus may not be generalizable to other races.Because the MCSA was originally designed to study the elderly population, the majority of patients were older than 60. This is older than the standard demographic for IIH , which iThis population-based study of LPs provides a 95% reference interval for OP in adults. The study confirms that OP is correlated with BMI and that there is an inverse correlation between OP and age among elderly patients. Although fairly repeatable, some patients can have significant changes in OP on serial LPs, with obesity contributing to the increased variability.All datasets generated for this study are included in the manuscript/supplementary files.FW and JC: conception and design of the study, acquisition and analysis of data, and drafting a significant portion of the manuscript or figures. EL, KK, and DH: acquisition and analysis of data, and drafting a significant portion of the manuscript or figures. JC-G, MB, JG-R, RP, DK, MM, GL, and JL: drafting a significant portion of the manuscript or figures.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.