Adults with cardiac implantable electronic devices (CIEDs) implanted at an early age constitute a specific group of patients undergoing transvenous lead extraction (TLE). The aim of this study is to assess safety and effectiveness of TLE in young adults. A comparative analysis of two groups of patients undergoing transvenous lead extraction was performed: 126 adults who were 19–29 years old at their first CIED implantation (early adulthood) and 2659 adults who were > 40 years of age at first CIED implantation and < 80 years of age at the time of TLE (middle-age/older adulthood). CIED-dependent risk factors were more common in young adults, especially longer implant duration (169.7 vs. 94.0 months). Moreover younger age of patients at first implantation, regardless of the dwell lead time, is a factor contributing to the greater development of connective tissue proliferation on the leads  and adhesions of the leads with the heart structures , which translates into worse TLE results in this group of patients. The complexity of procedures and major complications were more common in younger group , including hemopericardium  and TLE-induced tricuspid valve damage . Among middle-aged/older adults, there were 7 periprocedural deaths: 6 related to the TLE procedure and one associated with indications for lead removal. No fatal complications of TLE were reported in young adults despite the above-mentioned differences . Predictors of TLE-associated major complications and procedure complexity were more likely in young adults compared with patients aged > 40 to < 80 years. In younger aged patients prolonged extraction duration and higher procedure complexity were combined with a greater need for second line tools. Both major and minor complications were more frequent in young adults, with hemopericardium and tricuspid valve damage being predominant. The formation of this fibrous capsule in combination with somatic growth is a common source of mechanical lead damage and more difficult extraction in children than in adults10. To the best of our knowledge there is only one study addressing the peculiarities of lead extraction in young adults (< 40 years) compared with patients ≥ 40 years10. In the recent guidelines older age is considered as a risk factor for TLE-associated major complications and periprocedural mortality13. Life expectancy in young CIED carriers is long or very long and the guidelines recommend avoiding lead abandonment in this age group13.Permanent cardiac pacing therapy  is prescribed predominantly to older patients. Only a small proportion of cardiac implantable electronic devices (CIED) are implanted in subjects aged less than 40 years. Children and juveniles with leads implanted in childhood form a specific group of patients from the viewpoint of lead management and lead extraction in particular. Based on previous reports, the importance of rapid lead-induced tissue scarring and calcification has been emphasizedThe problem of lead extraction in young patients or older adults with CIED implanted in childhood is relatively unknown, and therefore requires detailed research. The purpose of the study was to compare effectiveness, complexity and major complications of transvenous lead extraction in patients aged 19–29 at the time of lead implantation and in subjects aged 40–80 at lead implantation/extraction. Patients with leads implanted in childhood and patients with TLE performed after the age of 80 were not included in this study because of age-specific differences.This post-hoc analysis used clinical data of 3344 patients who underwent transvenous lead extraction between March, 2006 and September, 2020. All information relating to patients and procedures was entered into the computer on an ongoing basis. For the purposes of comparison the cohort was divided into two groups: group A consisting of 126 adult patients who were 19–29 years old, mean age 23.6 ± 3.1, at their first CIED implantation (mean age at extraction 37.9 ± 9.2) and group B comprised of 2659 adults who were > 40 years of age, mean age 58.4 ± 11.5, at the time of their CIED implantation and < 80 years of age, mean age 66.5 ± 9.4, at the time of transvenous lead extraction. No other patient exclusion criteria were used. Some patients with very old leads or abnormal lead route  were referred for elective system replacement at our tertiary reference care center.14, with an online calculator available at http://alamay2.linuxpl.info/kalkulator/.This study analyzed demographic, clinical, CIED-related and procedure-related (including success and complications) data. The SAFeTY TLE score was used to predict the risk of major complicationsLead extraction procedures were performed using mechanical systems such as polypropylene Byrd dilator sheaths , mainly via the implant vein. If technical difficulties arose, alternative venous approaches and/or additional tools such as Evolution , TightRail  sheaths, lassos, basket catheters were utilized. Laser cutting sheaths were not used. In both groups lead extraction was performed by a team consisting of the same experienced operator, a second operator having experience with pacing therapy and a cardiac surgeon, whereas an anesthesiologist and echocardiographer were often but not always present during the procedure.12.Indications for TLE and type of periprocedural complications were defined according to the 2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction13.Extraction procedures of lead(s) older than one year were defined according to the guidelines on management of lead-related complications  portion of the lead that did not negatively impact the outcome goals of the procedure or permanently disabled the patient (only in patients with noninfectious indications for TLE)13.Partial radiographic success was defined as leaving a lead tip or a fragment of lead less than 4 cm2 test with Yates correction or because of the large disproportion in the size of the compared groups with the Mann–Whitney U test, as appropriate.The Shapiro–Wilk test showed that most continuous variables were normally distributed. For uniformity, all continuous variables are presented as the mean ± standard deviation. The categorical variables are presented as numbers and percentages. The significance of differences between groups was determined using the nonparametric Chivs non-infectious), kind of CIED system , presence/extraction of abandoned leads, number of leads in the heart (number of leads in the system + number of abandoned leads), number of CIED—related procedures before TLE and dwell time of the oldest extracted lead.To determine which parameters have impact on the major complications (MC) occurrence and clinical and procedural success the following variables were included in the regression analysis of risk factors of major complication and prognostic factors of clinical and procedural success: patient’s age during the first CIED implantation, patients age during TLE, gender, value of left ventricle ejection fraction, cteatinine level, body mass index, Charlson’s comorbidity index, indications for TLE .All patients gave their informed written consent to undergo TLE. The use of anonymous data from patient’s medical records was approved by the Bioethics Committee at the Regional Chamber of Physicians in Lublin, Poland no. 288/2018/KB/VII.All methods were performed in accordance with the relevant guidelines and regulations.The mean difference in age at the time of lead extraction between group A (patients with lead implanted in early adulthood ages 19–29) and B (patients with lead implanted at age > 40 and TLE performed before the age of 80) was 28.6 years (37.9 vs. 66.5). The mean difference in age at first lead/system implantation was 34.9 years (23.6 vs. 58.4). Compared with “ordinary” adults younger patients were more often women (46.8 vs. 37.4%). In young adults the most common indications for permanent cardiac pacing were congenital heart diseases, channelopathies, neurocardiogenic syncope and complications of cardiac surgery (82.5%), whereas in middle-aged/older adults ischemic heart disease, myocardial infarction (MI) and cardiomyopathies (77.5%). Age and indications for CIED are the indicators of difference in health status between the two groups, expressed as significant differences in average EF (59.2 vs. 47.8%), diabetes (2.4 vs. 21.1%), renal failure (3.2 vs. 20.4%) and Charlson comorbidity index (0.4 vs. 4.7). (Table 9–29 and Older patients were more likely to have infections compared with younger adults (32.3 vs. 21.4%), with the difference being significant for pocket infection (9.9 vs. 2.4%). Adults aged 19–29 were referred for lead extraction predominantly for noninfectious indications, mainly mechanical lead damage (46.0 vs. 25.7%). Middle-aged/older adults were more likely to have dysfunctional leads (12.5 vs. 5.6%) and system downgrading (0.8 vs. 3.8%), whereas younger aged patients more often underwent extraction of superfluous leads (10.3 vs. 3.2%). There were no differences in the type of CIED, excluding VDD (7.1 vs. 2.0%) and CRT-D (0.0 vs. 8.3%). Patients in group B tended to have more leads in the system than patients in group A (1.6 ± 0.5 vs. 1.8 ± 0.7 p = 0.003). Young adults had more, albeit insignificantly, abandoned leads (15.1 vs. 11.6%). Adults aged 19–29 were more likely to have more than 4 leads in the heart (3.2 vs. 0.4%), two single-coil ICD leads (8.1 vs. 0.6%), leads on both sides of the chest (5.6 vs. 3.0%) and more CIED-related procedures before lead extraction (2.4 vs. 1.9%) compared with patients aged 40–80. Young adults had significantly older leads: dwell time of the oldest extracted lead per patient was 172.1 months vs. 94.0 months in older adults and mean implant duration per patient before TLE was 152.3 vs. 86.8 months (Table 14 was significantly higher in early adulthood (8.7 vs. 5.7 points). Lead extraction in early adulthood was more time and effort consuming: extraction duration, expressed as “skin-to-skin time” (66.9 vs. 60.2 min), “sheath-to-sheath time” (22.3 vs. 14.8 min), and mean extraction time per lead (sheath-to sheath/number of extracted leads) (14.1 vs. 8.7 min) was prolonged in younger adults. Occurrence of any technical problem during TLE (34.1 vs. 19.6%), Byrd dilator collapse/torsion/"fracture" (11.1 vs. 2.9%) and lead fracture/rupture during the extraction (14.3 vs. 5.6%) were significantly more common in younger adults. Lead-to-lead binding (9.5 vs. 6.8%) and the need to use alternative approach (14.7 vs. 1.6%) were markedly but not significantly (lead-to-lead binding) more frequent in early adulthood. Lasso catheters/snares for broken lead fragments were significantly more commonly used in younger patients (12.9 vs. 3.2%). Similarly, Evolution (old and new) or TightRail sheaths (2.4 vs. 1.1%), loops formed with the catheter, guide wire and lasso  (2.4 vs. 1.8%) were more often required in young adults. Differences were not significant but a marked tendency was clear (Table Extraction of VDD lead 10.3 vs 2.4%) and abandoned lead(s) (13.5 vs. 10.8%) were more frequent in younger than older adults. The average SAFeTY TLE score used to evaluate the risk of TLE-related major complications as the number of points vs 2.4% The organizational model plays an important role in extraction procedures. It does not influence the occurrence of major complications but strongly facilitates their proper management and reduces procedure-related mortality. Both groups underwent TLE in the same time interval (selection was done retrospectively). Between 2006 and 2011 extractions were performed in the EP-LAB, between 2012 and 2016 additional precautions (graded approach) were taken and since 2017 all procedures have been performed in the hybrid room or cardiac surgery operating room. Table Major complications were observed more frequently in younger than older adults (7.1 vs. 2.0%), similar to hemopericardium (4.8 vs. 1.3%), need for immediate cardiac surgery (3.2 vs. 1.2%) and severe tricuspid valve damage during TLE (3.2 vs. 0.5%). The differences were significant in all but one variable (immediate cardiac surgery), reflecting well the disparity in TLE safety between the two groups. The comparison of the proportion of major complications depending on lead dwell time showed significantly higher percentage of MC in young adults (with the leads above 10 years old). TLE effectiveness expressed as complete radiographic success (86.5 vs. 95.7) and partial radiographic success (10.3 vs. 3.0%), similar to clinical success (93.2 vs. 98.1%) and procedural success (86.5 vs. 95.7%) was worse in younger than older adults. The relatively low percentage of procedural success was caused mainly by the lack of complete radiographic success (10.3 vs. 3.0%) but also because of the occurrence of permanently disabling complications (3.2 vs. 1.3%). Lead dwell time, number of the leads, presence of abandoned leads and redundant lead loops crossing the tricuspid valve and the occurrence of TLE-related TV dysfunction (increased TR by 2 or 3 degrees) (8.7 vs. 1.8%) were also of more importance in younger than older adults. Clinical success in both groups was comparable, but the rates of complete radiographic and procedural success were lower in younger adults. The relatively low rate of procedural success in both groups was caused mainly by the lack of complete radiographic success and because of the occurrence of permanently disabling complications (TV damage). Procedural and clinical success in young adults with the oldest leads (above 10 years) was significantly lower .In the group of older patients higher probability of MC occurrence was in patients with older leads—risk increase by 9.2% per one year , in female—risk increase by 236%  and in patients with higher number of previously CIED related procedures before TLE—risk increase by 30.3% per one procedure .Multivariable regression analysis shown that in the group of younger patients only the number of previously CIED-related procedures had the impact on clinical success achieving, decreasing probability by 67.2% per one procedure . In the group of older patients lower probability of achieving of procedural success was in patients with older leads—reduction by 8.4% per one year , higher number of leads in the heart—reduction by 40.8% per one lead  and in the patients with infectious indications for TLE—reduction by 88.1% .Multivariable regression analysis shown that in the group of younger patients the TLE of conventional pacemaker leads decreased probability of achieving procedural success by 75.1%  and each previously CIED—related procedures by 41.4% , but this parameter achieving borderline statistically significance. In the group of older patients lower probability of achieving of procedural success was in patients with older leads—reduction by 7.1% per one year , higher number of previously CIED—related procedures—reduction by 19.1% per one procedure  and in the patients with the higher number of leads—reduction by 26.2% per each lead   was an independent factor of the occurrence of major complications  and the lack of procedural success . Younger age of patients at first implantation, regardless of the dwell lead time, is also a factor contributing to the greater development of connective tissue proliferation on the leads  and adhesions of the leads with the heart structures , which translates into worse TLE results in this group of patients Table .Table 6B14 in combination with risk factors for short- and long-term mortality after lead extraction 16 often leads to an unjustified overestimation of TLE-related risk.Transvenous lead extraction is now an increasingly common procedure used in the therapy of CIED-related complications. The risk assessment of procedure is often difficult and misinterpreted. Knowledge of major complication predictors 5 and three reports on lead extraction in juveniles9, all of them confirming the difficulty of lead removal in these age groups9. There are also several reports on the expected increase in procedural risk but none of them has considered younger age of patients undergoing TLE as a risk factor for major complications21. Only one study uses the SAFeTY TLE score to assess the risk for the occurrence of major complications based on the following parameters: sum of dwell times of extracted leads , hemoglobin concentration (threshold level < 11.5 g/dl), female gender, the number of previous CIED-related procedures and less than 30 years of age at first CIED implantation14. The TLE score calculator is an online tool available at http://alamay2.linuxpl.info/kalkulator/.There are only five reports on lead extraction in children12, early removal of potentially dysfunctional leads should be considered in young people. As young patients have a very long life expectancy, abandonment of superfluous functional leads should be avoided, therefore the idea of prophylactic lead extraction needs further discussion.The current study shows that young adults were most likely to have congenital heart disease and complications of cardiac surgery. The majority of patients were in very good condition (Charlson comorbidity index 0.44). Noninfectious indications, especially mechanical lead damage were prevalent in young adults. There were no differences in CIED systems, but young adults had more abandoned leads and more leads on both sides of the chest and more previous CIED-related procedures. Currently, in accordance with the 2017 HRS consensus statement20. The present study confirmed that the effectiveness of the procedure was significantly lower in younger patients. Moreover, it has been shown that during lead extraction in young adults, technical problems occurred more frequently. Young adults more often needed the use of alternative approach and the second line tools . Mean extraction time per lead (sheath-to sheath/number of extracted leads) was longer in young adults (14.10 vs. 8.65 min). Major complications  were also more common in young adults (7.10 vs. 2.03%). This finding is consistent with that of El-Chami who compared two groups: < 40 years of age (n = 84) and ≥ 40 (n = 690) and showed that the younger cohort more frequently tended to require the second line tools and techniques despite similar lead dwell times in both groups (5.7 vs. 5.6 years)10. A slightly different result in our study can be accounted for by different implant duration: 172.1 vs. 93.95 months (14.34 vs. 7.83 years) and a very specific group of young adults (ages 19–29 vs. > 40 years) who seem to be nearer to children in terms of scar formation. Similarly, the analysis of the effectiveness of TLE in the population of young adults with congenital heart disease showed slightly better results, however the age of the extracted leads was lower compared to the present study21. As the evidence shows patient age has a significant impact on the severity of scar formation, and in consequence, lead extraction difficulty10.Multivariable analysis of the risk of major complications in the current study revealed only a few common risk factors for MC in young and older adults. The most important finding in younger adults was longer dwell time of the oldest lead before TLE. As is well known, longer lead dwell time is the main risk factor for complications of TLE10.This study aims to remind that in such specific patients lead extraction should be performed by most experienced operators in a high-volume center, as previously suggested by El-ChamiProbably age at CIED implantation is a strong, but largely underestimated risk factor for major complications associated with transvenous lead extraction.There are some limitations in this study. Extractions were performed based on the organizational model evolving from graded safety precautions between 2006 and 2015 to full safety precautions since 2017. All types of mechanical systems but not laser powered sheaths were used. TLE was performed in three centers by the same very experienced first operator. The database was created prospectively, but analysis was performed retrospectively.Lead extraction in young adults is often more complicated compared to the older population, because younger aged patients have a more pronounced connective tissue reaction to the presence of the lead and a dwell time of the oldest lead before TLE is usually significantly longer. These factors have the greatest impact on the effectiveness and safety of the procedure. In patients with their leads implanted in early adulthood prolonged extraction duration and higher procedure complexity are combined with a greater need for second line tools and clinical and procedural success are lower due to the lack of complete radiographic success. Moreover, both major and minor complications are more frequent in young adults, with hemopericardium and tricuspid valve damage being predominant.


To monitor Sweden’s progress towards the WHO goal of eliminating viral hepatitis, we estimated the prevalence, notification rate, and liver-related morbidity and mortality for diagnosed hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in 2015 and 2018.We identified cases of hepatitis B and C within the National System for Notifiable Diseases and obtained data on treatment and whether the case was deceased or not. We calculated prevalence, notification rates per 100,000, and proportion of newly diagnosed cases of hepatitis with liver disease at the time of diagnosis, and proportion of all deceased cases who died from liver disease. We calculated Poisson 95% confidence intervals (CIs) around the notification rates and Wilson 95% CIs around prevalence and mortality estimates.In 2015 and 2018, the prevalence of diagnosed HBV infections was 0.20% [95% CI: 0.19–0.20] and 0.21% [0.20–0.21]. Notification rates per 100,000 for HBV infections were 13.02 [12.32–13.76] and 7.71 [7.18–8.27]. HBV liver-related morbidity was 2.65% [1.90–3.68] and 2.16% [1.35–3.43]. HBV liver-related mortality was 20.00% [14.81–26.44] and 17.95% [13.20–23.94]. In 2015 and 2018, the prevalence of diagnosed HCV-infections was 0.24% [0.24–0.25] and 0.18% [0.18–0.19]. Notification rates per 100,000 for HCV infections were 15.92 [15.14–16.73] and 13.05 [12.36–13.77]. HCV liver–related morbidity was 8.14% [6.89–9.60] and 3.90% [2.99–5.08]. HCV liver–related mortality was 27.08% [24.54–29.77] and 26.90% [24.12–29.88].All indicators decreased or remained stable between 2015 and 2018, indicating progress in the elimination of viral hepatitis, especially for HCV infection. In 2016, the World Health Organization (WHO) set a goal to eliminate viral hepatitis as a major public health threat by 2030, defined as a reduction in hepatitis-related deaths by 65% and new chronic HBV and HCV infections by 90%, using 2015 as the baseline year  per 100,000 persons and 7.71 [95% CI: 7.18–8.27] per 100,000 persons, respectively  in 2015 and 92% (726/789) in 2018. In 2015, the estimated liver-related morbidity at the time of diagnosis was 2.65%  [95% CI: 1.90–3.68] while it was 2.16% (17/789) [95% CI: 1.35–3.43] in 2018.Among the 180 HBV-infected individuals who died in 2015, 36 (20% [95% CI: 14.81–26.44]) died of liver disease. In 2018, 195 HBV-infected individuals died of which 35 (17.95% [95% CI: 13.20–23.94]) died of liver disease. The proportion of deaths attributable to HBV infection was similar between men and women in both years (p > 0.05). There were no liver-related deaths among HBV-infected individuals younger than 30 years of age. We did not find a statistically significant association between age and liver-related HBV deaths in our data.When adding notifications with a temporary personal identification number, the total numbers of notifications of diagnosed chronic HBV infections were 35,592 and 39,107 for 2015 and 2018, respectively, corresponding to a prevalence of 0.36% [95% CI: 0.36–0.37] by the end of 2015 and 0.38% [95% CI: 0.38–0.39] by the end of 2018.When including notifications with a temporary personal identification number, the total numbers of new HBV notifications were 2376 and 1128, for 2015 and 2018, respectively, corresponding to notification rates of 24.12 [95% CI: 23.16–25.11] per 100,000 and 11.03 [95% CI: 10.39–11.69] per 100,000, respectively.The flow of notifications and applied assumptions is described in Fig. The sensitivity analyses for a clearance rate of 25% and 50% led to a prevalence of 0.28% [95% CI: 0.28–0.29] and 0.20% [95% CI: 0.20–0.20], respectively, in 2015, and 0.21% [95%CI: 0.21–0.22] and 0.15% [95%CI: 0.15–0.15], respectively, in 2018.In 2015 and 2018, notification rates of newly diagnosed HCV infections were 1568 infections or 15.92 [95% CI: 15.14–16.73] per 100,000 persons in 2015 and 1335 infections or 13.05 [95% CI: 12.36–13.77] per 100,000 persons, respectively  [95% CI: 2.99–5.08] in 2018.Among the 1108 HCV-infected individuals who died in 2015, 300 (27.08% [95% CI: 24.54–29.77]) died of liver disease. Among the 907 HCV-infected individuals who died in 2018, 244 (26.90% [95% CI: 24.12–29.88]) died of liver disease. The proportion of deaths attributable to HCV infection was similar between men and women in both years (p > 0.052). There were no deaths attributable to HCV infection in those younger than 20 years of age. The proportion of deaths was overall significantly different and higher in the older age groups (data not shown).When adding notifications with a temporary personal identification number to our analysis, the total numbers of diagnosed chronic HCV infections were 27,130 in 2015  and 22,424 in 2018 .When including notifications with a temporary personal identification number, the total number reported in 2015 was 1959 infections or 18.90 [95% CI: 18.07–19.76] per 100,000 persons and in 2018 there was 1609 infections or 15.13 [95% CI: 14.40–15.89] per 100,000 persons.This is the Public Health Agency of Sweden’s first follow-up to monitor Sweden’s progress towards the WHO goal of eliminating both hepatitis B and C as a public health threat until 2030.In 2015, the baseline year according to the definition by the WHO, the estimated prevalence and the notification rates of diagnosed HBV and HCV infections were already low when compared to the rest of the EU .The estimated prevalence of diagnosed chronic HBV infections increased slightly between 2015 and 2018. Since there is no effective curative treatment chronic infections will accumulate as long as the number of new cases exceeds deaths among the infected population. The notification rate of HBV infections on the other hand, decreased by 40% between 2015 and 2018. This decrease was especially striking among men. The majority of notified HBV infections were in immigrants who were likely infected as children in high-prevalence countries and then diagnosed after migrating to Sweden. This steep decrease after 2015 can be explained by reduced immigration to Sweden. In 2015, 162,877 asylum seekers came to Sweden, more than twice as many as in 2014 . MigrantThe estimated prevalence of diagnosed HCV infections decreased between 2015 and 2018, this is likely due to wider availability of DAA treatment. The rate of notification of newly diagnosed infections also decreased by 20%, which may be a result of several factors that have both reduced the prevalence of injecting drug use and made it safer. Such factors include large awareness campaigns for the risk of blood borne infections after HIV was discovered in the 1980s and HCV in the 1990s. They also include, more recently, increased coverage of needle-exchange programs where both the supply of clean equipment and screening for HCV have possibly lead to a reduced prevalence that in turn leads to a lower risk of being infected. The decrease in the rate of notification can also reflect changes in the prevalence of injecting drug use. The prevalence and notification rate of newly diagnosed HCV infections was highest in men and in young adults, which probably mirrors the epidemiology of injection drug use in Sweden , indicatWe did not observe any change in HBV-related morbidity at the time of diagnosis between 2015 and 2018. The HCV-related morbidity at the time of diagnosis decreased substantially between 2015 and 2018, hopefully indicating shorter time from primary infection to diagnosis. A possible explanation for this is that most of the birth cohort infected in the 1970s and 80 s (before the discovery of HCV) was diagnosed after a long time with HCV infection thus having an increased risk of developing liver-associated morbidity, and we now see a shift towards the diagnosis of HCV infection at a younger age before serious liver damage develops, possibly through the harm reduction programs that offer regular screening. Most deaths among HBV and HCV-infected individuals occurred in older age groups. There was no change in the proportion of deaths attributable to HBV and HCV infections between 2015 and 2018. This was likely due to the short monitoring timespan before the long-term effect of the new DAA treatment will be seen.These results need to be interpreted in light of some limitations. We focused our analysis on permanent Swedish personal identification numbers, thus excluding temporary Swedish personal identification numbers. This potentially underestimated the true prevalence and notification rates. However, including them would have led to an overestimate as we would not have been able to remove duplicate notifications. We assumed that for persons residing in Sweden for a longer time, a new HBV or HCV notification was created when the person visited health care after obtaining their permanent personal identification number.We made several assumptions regarding spontaneous clearance and cure rates in response to treatment. Firstly, we assumed the percentage of spontaneous clearance after diagnosis for acute HBV infections to be 5% for infants and 95% otherwise. We acknowledge that taking a sharp cut-off of 1 year of age for spontaneous clearance is likely to be clinically untrue. Since HBV infection among children in Sweden is very rare (mother-to-child transmission in Sweden is < 0.1%), and as a result an extremely small proportion of reported cases are diagnosed for hepatitis B when they are children, changing the cut-off from 1 to 5 years of age or assuming a slower over-time decrease would likely not affect the estimates measured in this paper . SecondlThe ICD-10 codes that we used for liver disease were the ones specified in the WHO framework. Even though this gives us the ability to compare our results to other countries using the WHO framework, the codes may not be the most appropriate for a Swedish setting, as demonstrated by a previous study by Duberg et al. , and thiFinally, our estimates are based on diagnosed and notified cases without estimating the infected but undiagnosed population. The ECDC estimates that only 20%–30% of all HBV and HCV infections are diagnosed in Europe . ConsequIn conclusion, this plan to monitor Sweden’s progress towards the elimination of HBV and HCV as a public health threat by 2030 can be used for regular follow-up. This first monitoring shows encouraging results for the first three years of 2015–2018, though subsequent follow-ups are warranted. Pandemic with COVID-19 has since 2020 possibly affected this elimination work and progress, and future studies are needed to assess the impact of this. We recommend that the progress should be monitored regularly until 2030.


In Latin America, we estimated 9.2% CrAg positivity (IC95% 7.9–10.7%) in patients with ≤100 CD4/mm3. Among patients newly diagnosed with HIV, we estimated 4416 incident cases per year in Latin America in those with <200 CD4/mm3 and 5289 in those with <350 CD4/mm3. In addition, we calculated the burden in people not on ARV or without viral suppression and found 28,672 cases. CrAg screening should be considered in patients who have a CD4 cell count < 350 cells/mm3. Cryptococcal meningitis was associated with 30.8% mortality in Guatemala. Global access to diagnosis as well as to liposomal amphotericin B and flucytosine is a priority. Cryptococcal disease is an important opportunistic infection among people living with HIV. The cryptococcal antigen (CrAg) can be detected before the clinical onset of meningitis and its screening is recommended. Here, we evaluated CrAg frequency, and describe the epidemiological characteristics and mortality at 180 days in a cohort of HIV patients from Guatemala. A total of 3457 patients were screened with a CrAg lateral flow assay in serum between January 2017 and December 2018. CrAg positivity was 11.5% in patients with ≤100 CD4/mm Cryptococcosis was associated with men . At enrollment, CD4 cell counts were available for 2589 patients (74.9%). The incidence of CrAg in patients with ≤100, <200 and <350 cells/mmectively . Patient to care  but this3 and from 7.9% to 11.2% in patients with AHD (references) (3 [3 [3 was 9.2% (IC95% 7.9–10.7%) and 8.1% in those with AHD (IC95% 7.9–10.7%). In other Latin American countries, published studies showed that CrAg positivity ranged from 8.1% to 12.7% in patients with <100 cells/mmerences) . For mors)  with a positive serum CrAg result had a lumbar puncture to rule out meningeal involvement. Sixty (65.9%) had cryptococcal meningitis. In a short survey, the health care facilities participating in the program stated that the main reasons for not performing a lumbar puncture were: patients’ refusal, lack of medical supplies, and clinical contraindications to performing a lumbar puncture. p = 0.322). Regarding cryptococcal meningitis, overall mortality at 180 days of follow-up was 38.3% (23 out of 60). Fifty percent (5 out of 10) of patients on ART died, whilst mortality was 28.6% and 38.9% in patients who return to care and among patients newly diagnosed with HIV, respectively. In patients who had a positive serum antigen but did not have a lumbar puncture, overall mortality was 30.3%. On the other hand, mortality in those with a negative CrAg lumbar puncture was 16.7% . Among these cases, three had coinfections, one had tuberculosis and two had histoplasmosis. It is important to take into account that although liposomal amphotericin B and flucytosine are recommended as antifungal treatments, none were available in Guatemala during the study period. Amphotericin B deoxycholate and fluconazole were the drugs used for treatment.One hundred and fifty-six cryptococcal cases were followed up at 180 days in this study; of these, 48 deaths (30.8%) were reported. Thirty-six (75%) of these deaths occurred in the first 30 days. 3 [3 [Among Latin American people with HIV, we estimated that CrAg positivity is 9.2% (IC95% 7.9–10.7%) in patients with <100 CD4/mm3 ,12,13,143 [3 ,13. Howe3 [3  that difOne of the most striking results of this analysis is the burden of cryptococcosis disease in patients who return to ARV therapy and those on ARV but with unsuppressed viral loads. The estimation of the burden of cryptococcal disease in PLWHIV and those with AHD could reach 28,000 cases. Considering the mortality rate observed in Guatemala at 180 days, we estimate that ≈8600 patients will die in Latin America due to a life-threatening disease which is easy to diagnose with a CrAg LFA. In Botswana, despite the wide availability of HIV testing and treatment services, a study showed that there was a substantial burden of cryptococcal meningitis due to a failure to effectively engage or retain patients in care . Several3, which is 8% higher than those diagnosed at <200 CD4/mm3. If we extrapolate our results for patients newly diagnosed with HIV in Latin America, we estimate that using a threshold of 200 CD4/mm3, 950 cases would have been missed in comparison to using a threshold of <350 CD4/mm3. Overlooked detection of positive cases has severe consequences because CrAg positivity is an independent predictor of meningitis and death [3. Of course the clinician’s judgment must prevail when the CD4 count is not available at evaluation but taking into account that cryptococcosis is a life-threatening disease, a CrAg LFA is cheap, easy to perform and provides a result within ten minutes, which allows making health interventions based on evidence.The CrAg LFA has a sensitivity and specificity of >98% . In Guatnd death . AccordiConcerning lumbar puncture, the WHO guidelines recommend performing a lumbar puncture to rule out meningitis in any CrAg LFA-positive patient . HoweverThe current recommended treatment for cryptococcal meningitis includes amphotericin B deoxycholate and flucytosine, followed by fluconazole . It is i3. Our analysis shows that the burden of cryptococcal disease among those with AHD in the region is substantially higher, reaching a prevalence of 31,503 cases. Although we calculated the numbers of cases for PLWHIV with AHD, the incidence of cryptococcal disease in Latin America for those with <100 CD4/mm3 is 3.2% higher than the global estimation, meaning that an underestimation of the burden of this life-threatening disease in this region is highly probable. There is very robust data for the Guatemalan cohort because of the number of patients included and the prevalence of cryptococcal disease in patients with <100 CD4/mm3 is 11.5%, almost 2-fold that reported for the global population (2), which further supports the estimations for this region. Optimal treatment of cryptococcal meningitis requires the integration of lumbar puncture as well as the availability of liposomal amphotericin B and flucytosine to reduce AIDS-related deaths.This study has limitations. The relatively low number of studies in the region and the lack of estimates concerning different groups of people living with HIV who are at high risk of cryptococcal disease could introduce changes in our estimates. Lack of detailed information regarding symptoms and ART adherence, which might influence outcomes, is not available. Furthermore, we define deaths in the cryptococcal disease group as attributable to this pathogen; however, patients with HIV could have additional comorbidities. Despite these limitations, this study shows a substantial burden of cryptococcal disease among people living with HIV in Latin America in addition to a high mortality rate, especially in those with cryptococcal meningitis and those without a lumbar puncture. Estimations by Rajasingham et al. (2) suggest a burden of 7000  cases for Latin America in PLWHIV with <100 CD4/mm


Blastobotrys (Arxula) raffinosifermentans (adeninivorans) was used for its synthesis by the desymmetrization of dicarboxylic acid diester diethyl adipate (DEA). Up to 78% MEA with 19% diacid adipic acid (AA) as by-product could be synthesized by the unpurified ACut2 culture supernatant from the B. raffinosifermentans overexpression strain. By adjusting pH and enzyme concentration, the selectivity of the free ACut2 culture supernatant was increased, yielding 95% MEA with 5% AA. Selectivity of the carrier immobilized ACut2 culture supernatant was also improved by pH adjustment during immobilization, as well as carrier enzyme loading, ultimately yielding 93% MEA with an even lower AA concentration of 3–4%. Thus, optimizations enabled the selective hydrolysis of DEA into MEA with only a minor AA impurity. In the up-scaling, a maximum of 98% chemical and 87.8% isolated MEA yield were obtained by the adsorbed enzyme preparation with a space time yield of 2.6 g L−1 h−1. The high monoester yields establish the ACut2-catalyzed biosynthesis as an alternative to existing methods.Monoethyl adipate (MEA) is a highly valuable monoester for activating resistance mechanisms and improving protective effects in pathogen-attacked plants. The cutinase ACut2 from the non-conventional yeast  Monoesters from symmetric dicarboxylic acids or diols possess two different functional groups—on the one side an ester group, and on the other side a carboxylate or an alcohol residue—offering different reactivities , middle.For oligonucleotide synthesis, dicarboxylate units are spacers between a phosphoramidite group bonded to a solid support and the first covalently attached nucleoside . In thatMonoesters can be obtained by ① esterification of a dicarboxylic acid and an alcohol or a diol and a carboxylic acid, ② hydrolysis of the diester, or ③ transesterification of the diester with an alcohol for dicarboxylic acid esters or with a carboxylic acid for diolesters , and only 1.6% of the unwanted side-product adipic acid (AA) -plot, and Hanes linearisation was performed, confirming the hyperbolic trend.Purolite carriers ECR1030M (divinylbenzene and methacrylate) for adsorption, as well as ECR8285 (epoxy/butyl methacrylate) for covalent bonding of the enzyme to a carrier, were preequilibrated with 10 mM buffer. After suction over a filter, enzyme preparations were added to the carriers. Immobilization was done at room temperature by slow rotation of the mixtures for 24 h. Carriers were sucked, washed with 10 mM buffer, and the used for hydrolysis reactions.DEA hydrolysis with ACut2-6hp culture supernatant was done in a volume of 44 mL. An enzyme activity of 20 U was used in 40 mL 100 mM sodium phosphate buffer pH 7.5. For immobilized ACut2-6hp, 20 U were bonded to 1 g ECR1030M or ECR8285 as described above, and 40 mL 100 mM sodium phosphate buffer pH 7.5 were added.The mixture was stirred and pH was set to 7.5 on the titrator, before the reaction was started by the addition of 4 mL DEA (453 mM). The pH of the reaction mixture was kept constant by titration with 5 M NaOH. Incubation was done at room temperature for one or two days.Products were isolated by two extraction steps with 40 mL MTBE. First, DEA was extracted at pH 7.5 and, after adjusting the pH to 2 with 12 M HCl, MEA and AA were isolated. Solvent was distilled off and fractions were analyzed via GC-FID, as described in A concentration of 50 mM DEA was hydrolyzed by the addition of 5 µL culture supernatant of the strain G1212/YRC102-ACut2-6H  in 100 mM sodium acetate buffer pH 5.0 in a reaction volume of 200 µL a.−1, and the concentration stayed nearly constant from 4 to 6 h at around 76%, and then decreased slowly. AA was synthesized nearly six times slower, with 3.5% h−1 over the whole time up to a concentration of 27%. The maximum MEA concentration formed was 78% with 19% AA being present.In 6 h, DEA was nearly completely hydrolyzed. Monoester MEA formed continuously for 4 h with nearly 20% hThe reason for the low selectivity of ACut2-6hp culture supernatant cannot be explained by impurities of the enzyme preparation with two other cutinases. DEA hydrolysis catalyzed by purified ACut2-6hp was non-selective for monoester synthesis as well (data not shown).The pH value during the reaction was varied to increase ACut2-6hp specificity for DEA monohydrolysis by culture supernatant b,c. In tHowever, pH optimization increased the yield of MEA by 14%, from 78% to 92%, whereas AA decreased by 12%, from 19% to 7%.MEA hydrolyzed only at a pH lower than 8 by ACut2-6hp culture supernatant, which confirms previous results d. The hi−1, DEA hydrolysis accelerated proportionally from 22 to 44% MEA formed in 2 h. The further increase of the enzyme concentration to 3.75 U mmol−1 and even higher (up to 15 U mmol−1) decreased the MEA concentration to 10% per 2 h. AA concentration was lower than 4% for all tested enzyme concentrations.Additionally, enzyme concentration determines reaction specificity a. When e−1 ACut2-6hp, only minimal AA was found after 16 h .M was determined for DEA and MEA as substrates with desalted ACut2-6hp supernatant . ACut2-6hp affinity was eight times higher to MEA compared to DEA at pH 4.9. Therefore, the specificity of ACut2-6hp for the DEA monohydrolysis is higher at pH 7.5 compared to pH 4.9.Nonetheless, it could be proven that the KPurified ACut2-6hp was adsorbed to copolymer of divinylbenzene methacrylate, as well as covalently bonded to epoxy/butyl methacrylate in 10 mM sodium acetate buffer pH 5 with yields over 99% for both variants concerning pNP-butyrate hydrolysis.Immobilization of purified ACut2-6hp changed the biochemical characteristics .Immobilized enzymes could be reused for more than 50 or 20 cycles, so there was no enzyme detachment. In addition, culture supernatant can be used for the immobilization with yields of 99.7% or 97.5% for adsorption or covalent bonding concerning pNP-butyrate hydrolysis. DEA was hydrolyzed unselectively (data not shown). That is the reason why the immobilization procedure and reaction conditions were optimized.Diacid formation should be reduced by optimizing the pH during immobilization, as well as the pH and temperature during the reaction.Immobilization at pH 5 to 9 in sodium phosphate buffer pH 7.5 at 30 °C was chosen for hydrolysis a,b. IncuWhen immobilization was done at pH 7.5, MEA concentration increased to 60% for the reaction at pH 5 to 6 or 6.5 for both immobilization methods c,d. MaxiInterestingly, 10% more AA was synthesized with covalently bonded ACut2-6hp at pH 5–6.5, with 40%. The influence of the reaction temperature on the selectivity was relatively low after optimization of the prior characteristics a,b. Reac−1 carrier obtained over 80% MEA yield for adsorption, and even lower loadings of 7.5 U g−1 offered a maximum MEA concentration of 93% for covalent immobilization. When higher activities were bonded on the carriers, MEA was further hydrolyzed to AA, which increased to 100% for enzyme loadings of 120 or 60 U g−1 carrier or higher.Enzyme loading of the immobilizates had a major effect on the selectivity of the DEA hydrolysis c,d. Only−1 carrier . Under these conditions, immobilization was successful with yields of 94.3% for adsorption and 89.0% for covalent bonding. Efficiency and activity recovery were in both cases over 100%, because activity was higher for immobilizates compared to the culture supernatant (data not shown). Thus, there has to be an activation of the biocatalyst ACut2-6hp by immobilization.Altogether, immobilizations as well as DEA hydrolysis reactions should be done at pH 7.5, between 20 to 30 °C, with enzyme loadings of 15–30 (adsorption) or 7.5–15 U gAfter optimization of DEA hydrolysis by different ACut2-6hp variants, it was scaled up to a volume of 40 mL. DEA concentration was increased eight times to 450 mM.−1 DEA . After one day of incubation, 3.4 g product was isolated by extraction of the whole batch  loaded to 1 g carrier . After 2−1h−1. In addition, product was unclear due to carrier dust, and there was an unknown peak found in the GC-FID measurement.Covalently bonded crude ACut2-6hp gave, under the same conditions, 2.8 g of 98% monoester and 2% diacid after 48 h incubation for 450 mM DEA concentration. This means that MEA yield decreased to 77.3% and STY to 1.12 g LIn summary, reactions with immobilized enzyme preparations gave a 5% higher product concentration with 11.5% more MEA inside, and thus they were more selective compared to that of the free enzyme. Covalently bonded ACut2-6hp is less attractive for MEA synthesis compared to the adsorbed preparation, although it seems to be the more selective enzyme preparation after optimization in the small scale. Adsorbed ACut2-6hp can be bonded with doubled loading capacity to the carrier, gave higher yields with up to 98% purity for MEA, and could be reused with an even higher substrate concentration and two-fold STY.Various dicarboxylic acid esters and diol diesters were hydrolyzed by ACut2-6hp culture supernatant under optimized conditions . The higWhen incubation time was prolonged, high monoester concentrations over 90% were obtained for diethyl adipate, diisopropyl adipate, dimethyl suberate, dimethylsebacate, and diethylsebacate.B. raffinosifermentans was used for the selective hydrolysis of the aliphatic dicarboxylic acid ester DEA to the monoester MEA. Non-optimized ACut2-6hp catalyzed DEA hydrolysis gave only MEA concentrations up to 78% because MEA was further hydrolyzed to the diacid AA (19%). This problem was overcome by various optimizations, gaining high monoester yields up to 98%.In this communication, the enzyme cutinase ACut2-6hp from the non-conventional yeast B. raffinosifermentans intracellular lipase Alip2, catalyzing pNP-butyrate hydrolysis best at pH 7 [The DEA hydrolysis by ACut2-6hp was only slightly affected by the pH value. Activity was highest at pH 7 and ranges from 84 to 81% at pH 4 to 7.5, which is in contrast to pNP-butyrate hydrolysis activity being at the maximum at pH 5, ranging from 47 to 67% at pH 4 to 6.5 . The pH  at pH 7 .M-values for DEA and MEA hydrolysis at pH 4.9 and 7.2 confirmed the lower affinity of ACut2-6hp to the substrate MEA with the increase of the pH. MEA hydrolysis is dramatically affected by pH increase, with an activity loss of 30% from pH 5 to 6 and 6 to 7, which resembles the pNP-butyrate hydrolysis . This pHIn addition, enzyme concentration influences the reaction. Surprisingly, the highest reaction velocity and selectivity were achieved at the identical enzyme concentration.Rhizopus oryzae lipase immobilized on Lewatit CNP 105 [−1 immobilizates. As immobilization on different supports influences different enzyme characteristics , and eve CNP 105 , the effImproving monoester yield by immobilization can be associated with changes in the enzyme structure in the case of lipases immobilized on hydrophobic supports via interfacial activation ,46. In aC. antarcitca lipase B in the same way. Lowering enzyme loadings and maintaining the pH close to 7 decreased the monoacid concentration from 1 to 0.6%.Guo et al.  minimizeIn the literature, there is much written about enantioselective desymmetrization of prochiral diesters by lipases to enantiopure products ,48,49,50This publication focused the desymmetrization of the even more simple non-prochiral aliphatic diester DEA. The reaction conditions for MEA synthesis from DEA were optimized to make the unselective ACut2-6hp selective. The monoester yield depends on pH and enzyme concentration, so that the influence of the incubation time was minimized.Finally, a chemical yield of 98% MEA was obtained in the present publication, which is higher compared to alternative methods.DEA saponification with NaOH under reactive distillation for the removal of the monoester gave only a 12% lower yield with 86% MEA . Babler Pseudomonas putida for monoester synthesis from fatty acids from C6 to C12. Further experiments have to be conducted to increase the molar yield, which is, at 0.75, relatively low.However, enzymatic methods were rarely used. Only van Nuland et al.  used a cB. raffinosifermentans, obtaining 96% MEA and 1.6% AA. Up to now, the reaction was not up-scaled. In addition, the enzyme was intracellular and had to be purified before use for DEA hydrolysis. This is cost- and time-consuming. The extracellular ACut2 containing supernatant was directly bonded to the support without further purification steps and gave up to 98% MEA with 2% AA in an up-scaled reaction. The DEA concentration was approximately 50 times higher compared to Ref. [Nietz et al.  describe to Ref. .These high MEA yields establish ACut2-6hp supernatant hydrolysis of diesters as an alternative method to existing methods for the production of aliphatic monoesters.Altogether, we here show that by optimizing reaction parameters, the unspecific ACut2-6hp can be used for the desymmetrization of DEA and other diesters with high monoester yields of up to 98%.−1 substrate. Under these conditions, 86.5% MEA with 6.2% AA and 7.3% DEA was synthesized and isolated in an up-scaled reaction. Even higher chemoselectivity, gaining 98% chemical pure MEA with only 2% AA, was reached after immobilization of the supernatant on carriers. Essential for this were optimizations of the pH, temperature and enzyme loading. Other diesters were also hydrolyzed chemoselectively under these conditions. Because no enzyme purification is necessary, time and costs are low. Compared to existing methods, yield is higher and the isolation methods are quite simple, making this enzymatic process with the available and efficient Acu2-6hp supernatant interesting for the production of aliphatic monoesters.The supernatant of ACut2 overexpression strain catalyzes the desymmetrization of aliphatic diesters chemoselective at pH 7.5 using an enzyme activity of 1.5 U mmolFor industrial application, a continuous reaction procedure should be developed to further reduce costs and time. The immobilized enzyme could be used in repeated batches, or new substrate could be added after the first reaction cycle while the product solution is removed in correspondence to NaOH addition. In addition, further diester hydrolysis reactions have to be tested in the up-scaling process to confirm the capability of ACut2 supernatant as a new biocatalyst for the production of monoesters.


We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre  from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1–278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F  = 5.505, P = 0.001.We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15–90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older . The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications  decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications. The term “amputation” derives from the Latin word “amputare” (“to excise” or “to cut out”), which means the removal of part or all of a body part delimited by the skin. Lower extremity amputation (LEA) consists of removing lower limbs by accident or surgery . LEA is The present study has described the clinical, biological, radiological profiles and therapeutic patterns of patients who underwent LEA in Togo from 2010 to 2020. In particular, we have analysed the characteristics of patients with DM who had LEA at Sylvanus Olympio Teaching Hospital (SOTH), which is the only one of the three tertiary hospitals in Togo equipped with a Wound Healing Unit.2, with a population of 8,849,000 in 2022, among which 5% were above 60 years. Togo was the first country to eradicate four tropical diseases  [This retrospective study was based on data retrieved from clinical files of adult (> 15-year-old) patients admitted and treated in the Wound Healing Unit and Traumatology-Orthopaedics department of Sylvanus Olympio Teaching Hospital (SOTH), in Lomé, the capital of Togo, from 1st January 2010 to 31st December 2020. Togo is a country in West Africa of 56,600 kmrachoma) . The heaThe patients admitted at SOTH enrolled in the current study came from Lomé and its surrounding areas.This study was conducted according to the World Medical Association’s Declaration of Helsinki  , Good ClSocio-demographic parameters Age (“aged” patients were those 65-year-old and older), sex, job;Past medical conditions and chronic diseases DM, hypertension, sickle cell disease;Charlson Comorbidity Index (CCI) was calculated from the files, and distributed in 4 groups: 0 (no comorbidity), [bidity), –4, ≥ 5 [bidity), , 27;Clinical characteristics Ischaemic or wet gangrene, tumour, crush syndrome;Biological parameters Haemoglobin rate, white cells count;Radiological findings Vascular lower limb ultrasonography;Histological nature of the amputated part;Therapeutic aspects and operative records Type of anaesthesia, side of amputation, amputation level , duration between indication and surgery, duration of hospital admission;Operative course Immediate and early postoperative complications (present or absent), which included death, psychological troubles, wound infections , the persistence of ischaemia, and disorders on the contralateral limb. The immediate complications were defined as those that happened in the first 24 h after surgery and the early those that happened from the first 24 h after surgery to the supposed date wound healing;Clavien–Dindo classification modified for foot and ankle surgery Ia (likely negligible), Ib , IIa , IIb (likely significant), IIIa , IIb (likely significant), IV, V (serious) [serious) , 29.From the clinical files, we retrieved the following data:We included clinical files of all adult patients who underwent an LEA at SOTH, of both sexes. We excluded missing or incomplete clinical files. We defined the incomplete files as those with more than half of the above parameters missing.We performed a descriptive statistical analysis of the data with CDC Epi Info Version 7.2.0.1 and Microsoft Office Excel 2013 software and provided the Chi-square value, degree of freedom, Fisher test, Odds Ratio (OR), confidence interval, and cell value P, if necessary. The cell values under 5% were considered significant.We used Microsoft Office Excel 2013 software for drafting tables and figures. We used the mean value to measure the age of the patients, rate of haemoglobin, hospital stay, and duration from indication to LEA.In the study period of 11 years (2010–2020), a total of 10,731 patients were admitted to the Traumatology-Orthopaedics department and Wound Healing Unit of Sylvanus Olympio Teaching Hospital. LEA was conducted in 363/10731 (3.38%) patients, and the average number of LEAs per year was 33. Figure The clinical files of 98/363 27%) patients operated on for LEA were missing. Of the 363 clinical files, 20 (5.51%) had incomplete information, and 245 (67.49%) contained enough information to be included in this study. Figure 7% patienThe mean age of the 245 patients who underwent LEA was 59.62 years (15.22 SD) (range: 15–90 years). Figure P = 0.023)  Table .Table 1DP < 0.001).The sex ratio of our patient population was 1.99. There was a statistically significant difference between male  and female patients   had a previous LEA. The previous LEAs of the 26 patients were minor (50%) and major (50%) amputations.Of the 245 clinical files, the past medical conditions were missing in 23 (9.39%) clinical files and present in 222 (90.61%). Of the 222 clinical files with data about past medical conditions, 143 patients had DM. Of them, 94 (42.34%) had DM alone, and 49 (22.07%) had DM associated with other comorbidities  patients had previous LEAs; of them, 20 (76.92%) were diabetic, and 6 (23.08%) were non-diabetic.Gangrene was the clinical presentation of the limb at hospitalization in 212/245 (86.53%) patients. Other clinical presentations were crush syndrome in 23/245 (9.39%), bone tumour in 5/245 (2.04%), osteomyelitis in 2/245 (0.82%), chronic ulcer in 2/245 (0.82%), and necrotizing fasciitis in 1/245 (0.40%) cases. Figure P < 0.001). The contralateral limb was amputated in 23.08% of patients after a minor amputation and in 53.85% after a major one.The 26 patients with previous amputations were more likely to have the same limb affected than the contralateral limb. The ipsilateral limb was amputated in 57.7% of patients compared to 42.5% of those with a contralateral limb (P = 0.308).Previous amputation was less common in patients with traumatic indications (5.9%) than in those with non-traumatic (11.9%), yet this difference did not reach statistical significance , 3 (9.25DS) . The rate of white cell anomalies (leukopenia and hyperleukocytosis) was significantly higher in patients with DM compared to those without DM . Patients with infection had the highest white blood cell counts, while those with tumours had the lowest haemoglobin (Table A complete blood count was registered in 235/245 (95.92%) clinical files. Patients with hyperleukocytosis accounted for 153/235 (65.11%). The count of the white blood cells was in the normal range for 80/235 (34.04%) patients; 2/235 (0.85%) patients had leukopenia. The average count of white blood cells was 15,646 elements/mmDoppler-ultrasound was performed in 91/245 (37.14%) patients; 18/91 (19.78%) patients were in the normal range, 42/91 (46.15%) displayed arterial abnormality , 6/91 (6.59%) had venous disorders , and 25/91 (27.48%) a combined artery and venous disorders.The causes of LEA were infections in 143/245 (58.37%) cases and bone or skin tumours in 5/245 (2.04%) . The odds of trauma as an indication for LEA were twice as high in those younger than 65 years compared to the older . Figure When we categorized age into less or more than 65 years, there was a significant association between age and the cause of LEA. Patients younger than 65-year-old had significantly more traumatic indications for LEA than those older (P = 0.052) (Table P = 0.01).Spinal anaesthesia was administered in 242/245 (98.78%) patients and general anaesthesia to 3/245 (1.22%). The side of the LEA was reported in 239/245 (97.55%) clinical files and missing in 6/245 (2.45%). LEA was left in 116/239 (48.54%) patients and right in 123/239 (51.46%). We found data about the amputation level in 241/245 (98.37%) clinical files: leg in 133/241 (55.19%) patients, knee in 14/241 (5.81%), thigh in 83/241 (34.44%), and foot in 11/241 (4.56%). There was no significant association between the aetiology of the LEA and the amputation level (The mean duration from the indication of amputation to the surgery found in 239/245 (97.55%) clinical files was 6.75 (1–78) days (11.59 SD).In the 237 out of 245 (96.73%) clinical files with recorded postoperative course, there was no immediate postoperative complications; there was a postoperative complication in 3/237 (1.27%); specifically, two patients had a stroke after the surgery, and one had a perioperative shock that raised favourably on medical treatment. Data regarding early postoperative complications were available in 238/245 (97.14%) clinical files. Complications were present in 56/238 (23.53%); the type of complications was reported in 47/56 (83.92%) clinical files and missing in 9/56 (16.08%) , sex (P = 0.96), level of amputation (P = 0.05), and presence or absence of DM (P = 0.97) (Table Early postoperative complications did not significantly differ according to age (7) Table .Table 4DP = 0.001).The mortality rate after LEA was 17/238 (7.14%). The mean hospital stay was marked in 241/245 (98.37%) clinical files and consisted of 36.30 (1–278) days (36.20 SD). The average hospital duration was 34.27 (27.86 SD) days for infections, 19.60 (20.62SD) for tumour, 32.44 (25.05 SD) for vascular aetiologies, and 63.25 (78.02 SD) for traumatic aetiologies. Patients with LEAs due to trauma had significantly longer hospital admission than those with non-traumatic indications  = 5.505, Our study has provided the updated pattern of LEA in Togo based on the data collected between 2010 and 2020 at the country’s main hospital (SOTH). The results have shown an overall improvement, but the causes of LEA and the socio-demographic features of the patients changed compared with the previous decades. However, the present study had an incomplete series of clinical files with data available for analyses.Considering the increase of the population of Togo from 5.01 million in 2000, 6.57 million in 2010 to 8.44 million in 2020 , the aveOf the 363 patients who underwent LEA at SOTH during the study period (2010–2020), we found 245 folders available for analysis. Therefore, the missed data represent a bias of the present study given the considerable number of absent or incomplete clinical files. Moreover, the incomplete series of sociodemographic or clinical characteristics of inpatient cases, such as marital status, address, religion, ethnic group, residual limb length, or phantom limb sensation, prevented us from assessing a possible association between these characteristics and LEA and reduced the range of feasible statistical tests. However, the information obtained from the complete clinical files accounted for relevant features of the LEA in our setting.The mean age of our patients who underwent LEA was 59.6 years. Ouchemi et al. in Tchad found a mean age of 47.0 years in 2016; Abalo et al. in Togo reported a mean age of 43.1 years in 2011, Kouassi et al. in Ivory Coast reported a mean age above 40 years in 2016; while Tobome et al. in Benin found a mean age of 37.4 years in 2015 , 20, 33.The sex ratio of our patient population was 1.99, with a statistically significant difference between female and male. Various authors reported the same male predominance in worldwide literature , 33, 34.Concerning the occupation of the patients, although the percentage of tailors is nearly 23% of the professions, we have not identified any clear association between work activities and LEA.In our series, the contralateral limb was more involved in LEA after major amputation than the minor. Some authors have reported similar data in the literature. Glaser et al. in the US found contralateral major amputation in 11.5% of patients and in 8.4% after a minor amputation at 5 years . HuseynoIn our series, DM was the predominant risk factor of LEA, accounting for 64.61% of the patients. This percentage of DM has increased compared to 48.2% previously found at SOTH during 2000–2004 , 35.The diabetic patients in our series had a significantly high hyperleukocytosis or leukopenia. However, there was no significant difference in infection rates between patients with and without DM in the early postoperative complications of LEA. In our setting, the first goal for patients with DM was to remove the gangrene and control infection. Therefore, the indication was major amputation, most in the leg, far from the foot infection. In contrast, many recent studies performed in Western countries reported a very low incidence of below-knee amputations (25.8–9.5%) and an increased number of foot amputations due to the high rate of revascularisation and endovascular surgeries . In our Our data missed post-histologic analysis of the amputated limb to reveal possible tumours. This deficiency could be due to a religious tradition, based on which, in case of death, patients’ families can request the amputated limbs for burial alone or with the whole patient’s body –41.In our study, the mean duration of hospitalization was 36.3 days. In developing countries, the mean hospital stay for LEA was more than 2 weeks and longer than that in developed countries. The hospital admission time of the patients with LEA due to trauma was significantly longer than others. This long hospitalization time can be due to staged procedures in traumatic patients, from damage control surgery to the stump refinement , 33, 42.The current pattern of LEA in Togo urges a multidisciplinary approach to improve soft tissue management after trauma, revascularization equipment, and post-surgery physiotherapy. It has also underscored the importance of a collaboration between in-hospital specialists and territory stakeholders. The involved specialists are orthopaedists, general or plastic or vascular surgeons, endocrinologists, cardiologists, geriatricians, internal medicine specialists, nutritionists, psychiatrists, prosthetics confectioners, physiotherapists and the territory stakeholders can be general practitioners and patients’ associations. This collaboration should focus on the lower limb pathologies leading to LEA early detection, and educational campaigns to prevent chronic cardiovascular diseases, especially DM.Our findings have prompted the importance of organizing a structured surveillance system as earlier recommended by Abbas et al.  that conFuture studies about LEA in Togo should be prospective, focused on the profile of the subset of the patients with DM undergoing this disabling surgery, and leverage a specific database.Notwithstanding an overall decreased incidence of LEAs at SOTH in Togo during 2010–2020 compared with previous decades, the still remarkable incidence in most cases correlates to chronic cardiovascular and cardiometabolic diseases, especially DM. This pattern of LEA imposes a multidisciplinary approach for screening programs, databases, a specific surveillance system, and clinical protocols and imaging monitoring.Patients who must undergo LEA in Togo should benefit from an improved surgical approach and post-surgery physiotherapy. Moreover, sensitizing all the healthcare stakeholders and the population through dedicated educational campaigns for DM prevention can reduce the high rate of LEA.


Premature infants frequently suffer from feeding intolerance related to prematurity and are highly associated with morbidity and mortality. Breast milk is fundamental to the improvement of the infant's immature vulnerable framework and decreases child mortality. The aim of this study was to find out the prevalence of feeding intolerance in premature neonates admitted to the neonatal intensive care unit of a tertiary care centre.This descriptive cross-sectional study was carried out among premature infants admitted to the Neonatal Intensive Care Unit of a tertiary care hospital from 15 December 2021 to 15 May 2022 after receiving ethical approval from the Institutional Review Committee (Reference number: 2211202103). Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated.Among the 55 preterm neonates, the prevalence of feeding intolerance was 21 (38.18%) .The study showed that the prevalence of feeding intolerance among neonates was higher than in studies conducted in similar settings. The study excluded any neonates suffering from intestinal congenital anomalies, neonates with fulminating sepsis from the onset, also neonates with milk allergies. Convenience sampling technique was done. The sample size was estimated using the formula:This descriptive cross-sectional study was carried out among all the cases with the diagnosis of prematurity admitted to the NICU of Kathmandu Medical College during a period of six months from 15 December 2022 to 15 May 2022 after receiving ethical approval from the Institutional Review Committee of KMC (Reference number: 2211202103). The study included all admitted preterm infants of both genders from day zero to day 28 of life and with gestational age (GA) from 22 to 36 weeks ,2p= prevalence of feeding intolerance among premature neonates taken from a previous study, 4.2%q= 1-pe= margin of error, 5%The calculated sample size was 43. A total of 55 preterms were included in this study.1 All the studied neonates were subjected to full history taking and full clinical examination.Diagnosis of feeding intolerance is considered by the presence of one or more signs that lead to interruption of the enteral feeding regime of the preterm as increased gastric residuals (>50%) of the previous feeding, greenish residual, hemorrhagic residual, emesis, abdominal distention , bloody stool, diarrhoea, visible bowel loops and apnea.The collected data were organised, tabulated, and statistically analysed by using IBM SPSS Statistics version 20. Point estimate and 95% CI were calculated.Among 55 preterm neonates, the prevalence of feeding intolerance was seen in 21 (38.18%) . The gestational age of enrolled infants ranged from 24 to 36 with a mean of 32.09±3.01 weeks of gestation. Similarly, the mean birth weight ranged from 0.70 grams to 2.60 grams with a mean of 1.65±0.48 grams. The mean time of diagnosis of feeding intolerance was found 3.61±1.68 days with a range from one to eight days. Among 21 preterms with feeding intolerance 13 (61.90%) were born at 28-32 weeks and 8 (38.10%) were at 33-35 weeks of gestation. A total of 10 (47.62%) preterm infants had clinical features of abdominal distension, 5 (23.81%) had apnea, 3 (14.29%) had gastric residues, and 3 (14.29%) had vomiting .In feeding intolerance 7 (33.33%) patients were found to have Hyaline Membrane Disease (HMD) followed by 4 (19.05%) with sepsis, and 3 (14.29%) with pneumonia .Most of the preterm infants, 48 (87.3%) were underexpressed breast milk and 7 (12.7%) were formula fed.2 A study done in Western Nepal shows similarity to this study in findings as the birth weight of babies ranged from 0.935 to 2.55 kg with a mean of 1.55 kg and this study also showed the birth weight of preterms ranged from 0.70 gram to 2.60 gram with mean of 1.65±0.48.6.In this study, it was observed that the gestational age of preterm neonates ranged from 28 to 36 with a mean of 32.09±3.01 weeks of gestation which was similar (32.1±2.3 weeks with a range from 28 to 36 weeks) to the study result done at a general hospital of Dhaka.7 The incidence of feeding intolerance also varied greatly in different studies done in different geographical areas, 4.2% in Dhaka, 36% in Bangladesh, 2.6% in Egypt, 34% in African Israelian and 15% in other Israelian, 11.02% in Western Nepal.10 The prevalence of feeding intolerance in this study was found to be 38.18% which is almost similar to a study done in Bangladesh,8 but higher than another Bangladeshi study.2 Here, the majority of preterm with feeding intolerance had features of, abdominal distension (47.6%) and some had apnea (23.8%), gastric residual 14.3%, and vomiting (14.3%). But unlike this study, in Western Nepal, 90.7% of all feed intolerant babies had vomiting followed by gastric residue, abdominal distension, reduced or absent bowel sounds and apnea respectively.6 Most of the other studies also had similar clinical presentations of vomiting, abdominal distension, gastric residual, and apnea.7 In this study, as regards the presence of other morbidities in the cases with feeding intolerance, it was HMD (33.3%) followed by sepsis (19%), and pneumonia (14.3%). Similar to ours, another study also detected HMD as the most common morbidity (23.7%), in preterm with feed intolerance.6In this study, the mean time of feeding intolerance diagnosis was found 3.61±1.68 days with a range from one to eight days whereas time at feeding intolerance diagnosis ranged widely from 3 to 25 days in a study done at Egypt.10In our observation most preterm neonates admitted to NICU (87.27%) started with expressed breast milk and the remaining (0.12%) were given formula milk. The World Health Organisation recommends the use of donor human milk (DHM) as a lifesaving alternative, especially for vulnerable, low birth weight, and preterm neonates.This study was conducted in a single centre with a limited sample size and a short time period for data collection, because of which the results may not be generalised to all preterm neonates. Adverse maternal conditions were not considered as exclusion criteria. Also, FI is a clinical diagnosis with an equivocal definition, which can be confused with other diseases.The study concluded that the prevalence of feeding intolerance among neonates was higher than in other national and international studies conducted in similar settings. Identifying the prevalence and knowing feeding practices in premature neonates will help us reduce mortality and morbidity due to prematurity.


To analyze the impact of previous cesarean section on rates of obstetrical hysterectomy among women with placenta previa.A retrospective cohort study done at the Department of Obstetrics & Gynecology, Nishtar University Hospital, Multan from January 2017 to December 2021. A total of 374 women aged between 20 to 50 years with diagnosis of placenta previa who underwent cesarean delivery were included. Age, BMI, area of residence, gestational age, gravidity status and past history of cesarean section were noted from medical records of all women. Relationship of previous number of cesarean sections and with obstetrical hysterectomy was noted among women with placenta previa.In a total of 374 women, mean age was 33.45±7.3 years. Mean gestational age was 37.4±3 weeks. Obstetrical hysterectomy was done in 110 (29.4%) women. Significant association of gravidity status was noted with hysterectomy as 95 (86.4%) women with hysterectomy had gravidity status ≥3 in comparison to 197 (74.6%) with no hysterectomy (p=0.030). Number of cesarean section was found to have significant association with obstetrical hysterectomy as 55 (50.0%) women with obstetrical hysterectomy reported ≥3 previous cesarean section versus 29 (11.0%) with no obstetrical hysterectomy (p<0.001).Strong association of previous number of cesarean section and obstetrical hysterectomy was found with placenta previa. There should be protocols for early identification and prediction of adverse outcomes among women with placenta previa with past history of cesarean section. Placenta previa is described as a condition in pregnancy where placenta implantation occurs abnormally in the lower uterine segment that could cover the internal cervical so partially or completely.4Massive hemorrhage, obstetrical hysterectomy and maternal death are some of the major and known complications of placenta previa.9The chances of maternal and perinatal morbidity are increased among women with placenta previa but not much research has been done to find out relationship of hysterectomy with past CS history in women with placenta previa. Our aim was to analyze the impact of number of previous cesarean section on rates of obstetrical hysterectomy among women with placenta previa. The findings of this study were thought to help clinicians predict the risk of obstetrical hysterectomy among women having placenta previa who present with previous history of CS which may assist us in devising some strategies to reduce cesarean section rates among these women.This retrospective cohort study was conducted at the “Department of Obstetrics & Gynecology, Nishtar University Hospital, Multan” from January 2017 to December 2021. Approval from “Institutional Ethical Committee” was acquired . A total of 374 women aged between 20 to 50 years with diagnosis of placenta previa who underwent cesarean delivery were included.Age, BMI, area of residence, gravidity status, gestational age and past history of cesarean section were noted from medical records of all women. Obstetrical hysterectomy was considered as the main outcome. Relationship of previous history of cesarean section with obstetrical hysterectomy was noted among women with placenta previa.SPSS version 26.0 was employed for data handling and analysis. Frequencies and percentages were used to represent categorical variables. For numeric data, mean and standard deviation (SD) were calculated. Comparison of qualitative data was made using chi-square test while quantitative data was compared utilizing independent sample t-test. P value ≤ 0.05 was taken as significant.2 (ranging between 22-32 kg/m2) while 186 (49.7%) women had BMI below 25 kg/m2. There were 292 (78.1%) women who had gravidity status ≥ 3 (ranging between 1 to 9). Previous history of lower segment CS was noted in 188 (50.3%) women. In a total of 374 women, mean age was 33.45±7.3 years while 165 (44.1%) women were aged between 31 to 40 years. There were 214 (57.2%) women from rural areas of residence. Mean BMI was 25.7±2.8 kg/mObstetrical hysterectomy was done in 110 (29.4%) women. No significant association of hysterectomy was noted with different age groups (p=0.453), area of residence (p=0.483) or BMI (p=0.122). Significant association of gravidity status was noted with hysterectomy as 95 (86.4%) women with hysterectomy had gravidity status ≥3 in comparison to 197 (74.6%) with no hysterectomy (p=0.030). Comparison of characteristics of women with respect to obstetrical hysterectomy is shown in Previous history of CS was found to have signification association with hysterectomy as 55 (50.0%) women with hysterectomy reported ≥3 previous cesarean section in comparison to 29 (11.0%) patients without hysterectomy (p<0.001). In comparison to no past history of CS, there was 1.9 fold increase in the risk of hysterectomy with one cesarean section, 2.6 fold with two cesarean sections and 5.5 fold increase with three or more cesarean sections. Association of number of previous CS with obstetrical hysterectomy is shown in Mean age of the women with placenta previa was 33.45±7.3 years while 44.1% women were aged between 31 to 40 years and 26.5% between 41 to 50 years. Local data evaluating cases of placenta previa undergoing cesarean delivery noted mean age of women to be 28.6±4.5 years which is somewhat lower than what was noted in this study.11We noted that 50.3% women had previous history of cesarean section. Wasim T et al.10In the present study, cesarean hysterectomy was done in 29.4% women with placenta previa. Maqsud M et al. from Lahore reported rates of hysterectomy to be 19.2% among women with placenta previa.12In this study, previous history of CS had signification association with hysterectomy as 47.3% women with hysterectomy reported ≥3 previous cesarean section in comparison to 11.0% of patients with no hysterectomy (p<0.001). Likewise, 9.1% women with hysterectomy performed reported no history of previous cesarean section in comparison to 66.7% cases where hysterectomy was not performed (p<0.001). The risk of placenta previa has been reported to increase by 0.28–2% in patients who have undergone at least one CS in a meta-analysis including 36 trials.18Retrospective study had its own limitations. As this was a single center study, our findings cannot be generalized. We were unable to find out other most commonly occurring maternal adverse outcomes due to lack of availability of data. We also could not evaluate fetal outcomes and its relation with past history of cesarean sections performed among women with placenta previa.In our study, strong association of previous number of cesarean section and obstetrical hysterectomy was found among women with placenta previa. Due to associated maternal morbidity and maternal mortality, there should be protocols for early identification and prediction of adverse outcomes among women with placenta previa with past history of cesarean section.


Objective: The present study assesses the effect of the proportion of tissue resected during transurethral resections of the prostate (TUR-P) on lower urinary tract symptoms (LUTS) and other parameters in patients with a benign prostatic obstruction (BPO).Materials and methods: Forty-three patients who underwent TUR-P between 2018 and 2021 were assessed prospectively. The patients were divided into two groups according to the percentage of tissue removed . Age, prostate volume, amount of resected tissue, operative time, length of hospital stay, duration of catheterization, International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum urinary flow rate (Qmax), and serum prostate-specific antigen (PSA) (ng/dl) at preoperative and postoperative three months were recorded.Results: The percentage of tissue removed was 22.2% vs. 48.4% (p = 0.001), IPSS reduction was 77.7% vs. 83.3% (p = 0.048), QoL improvement was 77.2% vs. 84.8% (p = 0.133), Qmax increase was 171.3% vs. 193.5% (p = 0.032), and serum PSA decrease was 56.4% vs. 69.2% (p = 0.049) in groups 1 and 2, respectively. In addition, the operative time was 38.5 vs. 53.6 min (p = 0.001), the length of hospital stay was 2.0 vs. 2.4 days (p = 0.001), and the duration of catheterization average was 4.1 vs. 4.9 days (p = 0.002).Conclusion: Resections of at least 30% of prostatic tissue can provide a significant improvement in the symptoms and parameters related to benign prostatic obstruction, while resections of less than 30% of prostatic tissue can effectively reduce urinary symptoms and improve the quality of life in older adult patients with comorbidities who require shorter operating times. Benign prostatic hyperplasia (BPH) is one of the most common health problems in aging men and is a histological diagnosis that is evident in almost every long-living man (90% of men by the age of 90 years) . In a stSurgical treatment is often recommended for patients who do not benefit from medical treatment or who develop BPH-related complications  . TransurThis prospective study assesses the amount of prostatic tissue resected and postoperative outcomes in patients undergoing TUR-P for BPH, and predicts the amount of tissue that should be resected to relieve LUTS related to BPH.This study was conducted after gaining the approval of the Gaziantep University Faculty of Medicine (GUFM) Clinical Research and Ethics Committee (Decision date: 03.07.2019 and No. 2019/263).Study participantsA total of 43 patients who underwent TUR-P for moderate-to-severe LUTS due to BPH between 2018 and 2021 were assessed prospectively.Patients with moderate-to-severe LUTS due to BPH despite medical treatment, an International Prostate Symptom Score (IPSS) of >8, Qmax of <15 ml/sec, benign prostate biopsy, if performed, no serum prostate-specific antigen (PSA) and digital rectal examination (DRE) findings of malignancy, were included in the study. Patients who preoperatively had prostate or bladder cancer, urethral stricture, neurogenic bladder, bladder dysfunction, and those on medication that might lead to voiding dysfunction were excluded.The study patients were assessed on the proportion of prostatic tissue removed, with those undergoing a <30% resection assigned to group 1 (n = 20) and >30% to group 2 (n = 23).Surgical technique and sample collectionPreoperatively, all patients were evaluated based on their medical history, DRE, uroflowmetry, serum PSA test, complete urinalysis, complete blood count, biochemistry, and coagulation tests. The patients' symptoms, IPSS, and quality of life scores (QoL) were recorded . ProstatAll patients were operated on by the same surgeon. Regional cleaning and appropriate draping in the lithotomy position were performed under spinal or general anesthesia, and adenoma in the transitional zone and the median lobe, if any, were resected using an Olympus 26-Fr continuous-flow resectoscope and a standard electrode  with isotonic saline irrigation. After bleeding control, a three-way catheter was inserted for continuous irrigation. Operative times were recorded. Prostatic tissue specimens were filtered thoroughly after the surgical procedure, weighed on a sensitive balance and recorded in grams (g). Since formaldehyde may cause a tissue weight loss of 10-13%, the specimens were placed in formaldehyde after weighing.Follow-upComplications that developed during surgery or at follow-up were noted and classified according to the modified Clavien-Dindo system . The lenThe proportion of tissue removed was calculated using the formula: weight of tissue resected × 100/prostate volume on the preoperative ultrasonography (US).Statistical analysisSPSS for Windows  was used for the statistical analysis, with data expressed as an arithmetic mean and standard deviation. A chi-square distribution test was used to calculate categorical variables and a Mann-Whitney U test to compare means. A confidence interval of 95% (p < 0.05) was considered statistically significant.Preoperative assessment3 vs. 77.7 ± 35.08 cm3, p = 0.081). Preoperatively, group 2 had a higher IPSS score , a lower Qmax , and a greater decrease in QoL  than group 1. Preoperatively, the mean serum PSA was 5.71 ± 5.9 ng/ml in group 1 and 9.1 ± 9.5 ng/ml in group 2 (p = 0.059) . There was no statistically significant difference in the mean prostate volumes of group 1 and group 2 preoperatively, although it was lower in group 1 (60.9 ± 30.1 cmPostoperative assessmentThe mean amount of prostatic tissue resected was 14.3 ± 9.6 g (22.2 ± 5.73%) in group 1 and 39.4 ± 25.7 g (48.4 ± 15.7%) in group 2 . There was no difference in the improvement in quality of life scores between the two groups . The percentage of IPSS reduction and the increase in Qmax were higher in group 2  .Postoperatively, the PSA level was 2.2 ± 2.4 ng/ml in group 1 and 2.6 ± 2.4 ng/ml in group 2, and the percentage PSA decrease was higher in group 2  (p = 0.049). Group 2 had statistically significantly longer operative time, longer hospital stay, longer urethral catheterization, and higher percentage of hemoglobin reduction  (Table Postoperative blood transfusion was administered to two (4.6%) of the 43 study patients due to bleeding (Clavien II)-one in group 1 and the other in group 2. Uncomplicated urinary tract infection (UTI) occurred in four (20%) group 1 patients and four (17.3%) group 2 patients, totaling eight (18.6%) patients (Clavien I). Membranous urethral stricture developed in one (5%) group 1 patient and in the bulbar urethral stricture in one (4.3%) group 2 patient, and the stricture was relieved in these patients using a cold urethrotome knife under local anesthesia (Clavien IIIa). There was no statistically significant difference in the complications between the groups (p = 0.778).The TUR-P surgical approach was first defined in the 1930s and remains the most popular and optimum approach to surgical treatment in patients with obstruction-related symptoms and a prostate volume of 30-80 g [The study by Liu et al. reported no correlation between the percentage of prostatic tissue removed from the transitional zone following TUR-P and the surgical outcome . Among tAmong the studies involving the calculation of the amount of prostate removed, Green et al.  reportedIn the present study, group 1 comprised patients who had less than 30% of tissue resected (n = 20), and group 2 consisted of patients who had more than 30% of tissue resected (n = 23). In our review of the literature, Antunes et al.  were conSerum PSA is normally used to screen for prostate cancer. The study by Bohnen et al., involving a large patient series, established a strong relationship between PSA and prostate volume . This stYoon et al. reported a 116% increase in Qmax in a sample of 49 patients with a resection rate of 28% . In anotSurgery for BPH is often performed on middle-to-advanced-aged patients, which sometimes makes it difficult to deal with complications and is associated with significant mortality and morbidity. The study by Mebust et al. found an increased risk of complications in patients with a prostate of >45 g and an operative time of >90 min . Common Operative time is important for the development of complications. Wilhelm et al. resected 51% of tissue in a mean of 55.3 min in patients with a prostate volume of <70 cc and 54% of tissue in a mean of 82.6 min in those with a prostate volume of >70 cc . Bach etStudy limitationsIn the present study, we used TAUS to calculate the prostate volume of patients. Studies have shown transrectal ultrasonography (TRUS) and MRI to be more accurate than TAUS in revealing the anatomy and measuring the size of the prostate . AlthougThe standard TUR-P technique recommends the resection of all existing adenomas, and this method has been widely adopted by surgeons. Candidates for TUR-P are often older adults and are likely to have comorbidities, leading to increased morbidity and mortality rates due to prolonged operation times and a greater amount of tissue removed ,28. The According to our findings, a resection rate of at least 30% provides a significant improvement in symptoms and the parameters related to benign prostatic obstruction. Resections of at least 30% of prostatic tissue can adequately relieve lower urinary tract symptoms and improve the quality of life in older adult patients with comorbidities who require shorter operating times. Owing to the limited number of similar studies in the literature, there is a need for studies of similar design that present long-term outcomes.