The primary end point was the percentage of pathological complete responses (pCR) in the breast; secondary end points were tolerability, clinical response rates, overall and progression-free survival, tumour biomarkers before and after primary chemotherapy (PCT). All patients were included in safety and survival analyses; 41 eligible patients were evaluated for response. The overall clinical response rate was 87.8% (95% CI 77.8–97.8), with 26.8% complete responses (95% CI 13.3–40.3). A pCR in the breast was observed in six patients ; 15 patients  had negative axillary lymph nodes. Grade 4 neutropenia was observed in 67.4% of the patients; febrile neutropenia occurred in 1.9% of cycles (granulocyte colony-stimulating factor was used in 3.2% of the cycles to shorten the duration of neutropenia). A statistically significant difference between Mib-1 at baseline (⩾20% in 71.4% of the patients) and at definitive surgery  was observed. The gemcitabine, epirubicin, taxol regimen is active and well tolerated as PCT for operable breast cancer. This combination allows the administration of full doses of active agents with a low incidence of febrile neutropenia.This trial was conducted to assess the activity and tolerability of the gemcitabine, epirubicin, taxol triplet combination in patients with operable breast cancer. After core biopsy, 43 women with stage II–IIIA breast cancer were treated with gemcitabine 1000 mg m An objective response was observed in more than 50% of the patients, radical surgery was feasible in most of the cases, and prolonged disease-free and overall survival were reported  test new regimens with a validated short-term end point (pCR); (2) design tailored treatments based on the observed response; (3) identify tumour biomarkers with prognostic and/or predictive value.We have recently shown that the combination of gemcitabine plus epirubicin and taxol (GET) is feasible and extremely active in metastatic breast cancer ; adequate renal and hepatic function ); normal cardiac function determined by electrocardiogram and left ventricular ejection fraction (L-VEF); World Health Organization (WHO) performance status ⩽2; aged 18–70 years; compliance and geographic proximity; childbearing potential terminated or attenuated by use of an approved contraceptive method; written informed consent. The noneligibility criteria were: locally advanced disease (stage IIIB) or inflammatory breast carcinoma; multifocal breast carcinoma; active infection; calcium above the ULN; presence of distant metastases; other serious medical illness . Pre-study staging included physical examination, mammography and/or ultrasonography of the breast, chest radiography, bone scan, liver ultrasonography, echocardiography and haematological blood tests.Patients with histologic diagnosis of breast cancer who met the following criteria were eligible: stage II–IIIa (tumour size ⩾2 cm) determined by physical examination and mammography; adequate bone marrow reserve  bolus on day 1 and taxol 175 mg m−2 as a 3-h infusion on day 1, every 21 days for four cycles. In order to prevent severe hypersensitivity reactions, patients received a premedication with dexamethasone 20 mg i.m., orphenadrine 50 mg i.m. and cimetidine 300 mg i.v.After core biopsy, patients were treated according to the following schedule: gemcitabine 1000 mg m9 l−1, absolute neutrophil count was ⩾1.5 × 109 l−1 and platelet count was ⩾100 × 109 l−1; if these values were not reached, treatment was delayed until recovery. All drugs were reduced by 25% in case of febrile neutropenia requiring hospitalisation and/or i.v. antibiotics, grade 4 thrombocytopenia lasting more than 3 days and/or associated with bleeding, or grade 4 neutropenia lasting more than 7 days. In case of grade 3 nonhaematological toxicities , all drugs were reduced by 25%; all drugs were reduced by 50% for grade 4 toxicity. In the case of grade 1 neurotoxicity, taxol was reduced to 135 mg m−2, and in the case of grade 2 neurotoxicity, taxol was discontinued. The protocol permitted use of granulocyte colony-stimulating factor (G-CSF) as prophylaxis after episodes of febrile neutropenia. Patients with hypersensitivity reactions received supportive measures and were treated again with taxol at a slower rate of infusion.Complete blood count was determined on day one of each cycle and then twice a week. Treatment was permitted if white blood cell count was ⩾3.0 × 10Patients who developed progressive disease were taken off the study.After four cycles of chemotherapy, breast surgery was performed according to local procedures. Patients received either modified radical mastectomy or lumpectomy with axillary dissection of level I–II axillary lymph nodes.Adjuvant postoperative chemotherapy was left to the discretion of the treating physician; however, two additional courses of chemotherapy were recommended in cases of positive lymph nodes. Premenopausal receptor-positive patients received tamoxifen 20 mg daily for 5 years plus luteinising hormone-releasing hormone inhibitors for 2 years. Postmenopausal receptor-positive patients received tamoxifen 20 mg daily for 5 years.In cases of breast conservative surgery, postoperative irradiation with a 4–6 MeV linear accelerator or modern cobalt-60 unit was administered. Radiotherapy was started after completing chemotherapy.Clinical assessment of tumour and nodal size was performed by physical examination, mammography and/or ultrasonography before starting chemotherapy, and again before surgery.Clinical response was defined as follows: complete response is the disappearance of all clinically detectable disease; partial response is a ⩾50% decrease in the products of the two largest tumour diameters; stable disease reflects changes in tumour burden that do not indicate a progressive disease or clinical complete or partial response. Progressive disease was defined as at least a 25% increase in the sum of the products of bidimensionally measurable disease or the appearance of new lesions.Pathological complete response was defined as no histologic evidence of invasive or noninvasive tumour cells in the breast. Toxicity was evaluated according to the common toxicity criteria of the National Cancer Institute. Progression-free and overall survivals were calculated according to Kaplan–Meier curves from day 1 of the first cycle. All registered patients were included in the analysis of toxicities and survival. Eligible patients only were included in the primary efficacy analysis.The following biological markers were assayed at baseline and on the surgical specimens: hormone receptor, Mib-1, Scarff–Bloom–Richardson grade and Her-2-neu expression. All the biological markers were measured in a centralised laboratory.The primary end point was the pCR rate. Secondary end points were: toxicities, overall response rate, survival and progression-free survival, and tumour biological profile before and after PCT.α error=0.05, β error=0.10; P0  and P1 (sufficiently promising true response rate) were set at 5 and 20%, respectively. In all, 21 patients had to be enrolled in the first stage: if ⩽1 pCR were observed, the accrual was stopped. In case of ⩾2 pCR, 20 more patients were entered at the second stage. The regimen was considered sufficiently active to deserve further studies if ⩾5 pCRs were seen.Simon's optimal two-stage design for phase II clinical trial was used to calculate the sample size, with the principal study end point being the pCR rate. The sample size was calculated on the following assumptions: A total of 44 women with stage II–IIIA disease from five Italian institutions were enrolled into the study; one patient was not included in the full analysis set for refusal. In all, 41 patients were eligible, two patients were not included in the primary efficacy analysis due to the existence of bilateral breast carcinoma. The characteristics of the patients are shown in All eligible patients were evaluable for response. The overall clinical response rate was 87.8% (95% CI 77.8–97.8), with 61% of the patients experiencing a partial response and 26.8% (95% CI 13.3–40.3) a complete response; stable disease was observed in five patients (12.2%).A pCR was observed in six patients (14.6%) (95% CI 3.8–25.4); 15 patients (36.6%) (95% CI 21.9–51.3) had negative axillary lymph nodes.The pCR rate was analysed as a function of pretreatment clinical stage and biological characteristics. Two pCRs were observed among five patients with tumours less than 3 cm (40%), three among 25 women with tumour size between 3 and 5 cm (12%), and one in 11 patients with tumours larger than 5 cm (9.1%). The pCR rate was 9.7% (three out of 32) in oestrogen receptor-positive and 25% (two out of eight) in oestrogen receptor-negative tumours, 17.4% (four out of 23) in Mib-1 ⩾20 and 7.7% (one out of 13) in Mib-1 <20% tumours, 20% (one out of five) and 4% (one out of 25) in Her-2-positive and -negative tumours, respectively; none of these differences reached statistical significance.At a median followup of 29 months (range 12.2–51), nine patients had developed progressive disease and three patients had died .In all, 43 patients were evaluable for toxicity. During the study, 172 cycles of chemotherapy were administered and were evaluable for toxicity.The main haematological toxicity was neutropenia, with grade 4 episodes observed in 67.4% of the patients. Febrile neutropenia occurred in 1.9% of cycles, while G-CSF was administered in 3.2% of the cycles to shorten the duration of neutropenia. Only one episode of grade 3 anaemia was observed, while thrombocytopenia was mild, with 9.3% of patients experiencing a grade 3 toxicity . One redNo episode of grade 4 nonhaematological toxicity occurred. Nausea/vomiting and mucositis grade 3 were observed in 9.3 and 7% of the patients, respectively. Grade 1–2 neuropathy was observed in 18.6% of the patients. Cutaneous toxicity was mild, with 41.9% of the patients experiencing grade 1–2 toxicity .No clinical cardiac toxicity or significant decrease of L-VEF was observed.All the patients underwent surgery for breast cancer. In all, 19 patients (44%) were treated with lumpectomy and axillary node dissection, and 24 patients (56%) received modified radical mastectomy.P<0.05). Her-2-neu expression was also modified by chemotherapy even if the difference was not significant: it was positive in 21% of the patients at baseline and in 10.5% at surgery. Biological data are summarised in The expression of hormonal receptor status and nuclear grading were not modified by chemotherapy. A statistically significant difference between Mib-1 at baseline and at definitive surgery was observed: Mib-1 ⩾20% in 71.4% of the patients at baseline and in 28.6% at surgery ; however, it was short lasting, rarely requiring G-CSF administration (3.2% of cycles), and resulted in very few episodes of febrile neutropenia (1.9% of cycles), significantly lower than that observed in an adjuvant trial with a three-drug regimen including docetaxel, doxorubicin and cyclophosphamide , the dose of gemcitabine was reduced to 800 mg m−2 on days 1 and 8, epirubicin was administered at 90 mg m−2 and filgrastim support was required.Conservative surgery was not an end point of the study and no guideline for conservative surgery was included in the protocol; this reason and the fact that the patients were treated in five different hospitals may explain the relatively low percentage of conservative surgery (44%). The high activity of this triplet regimen has been confirmed by Comparable pCR rates have been obtained with other regimens containing taxanes, anthracyclines or antimetabolites (vs 9.7%), Mib-1 ⩾20% (17.4 vs 7.7%) and Her-2 overexpression (20 vs 4%).Primary chemotherapy provides the ideal setting to investigate prognostic and predictive factors; apart from pCR, the most powerful predictor of long-term outcome is the status of axillary lymph nodes. In our study, 36.6% of the patients had negative axillary lymph nodes at surgery. However, the nodal status was not pathologically documented at study entry, and it is therefore impossible to measure the effect of treatment on this parameter. Many predictive factors of response have been studied, and several authors have reported that hormone receptor negativity, high histological grade and high Ki-67 levels correlate with pCR, while the predictive value of Her 2 expression, bcl-2 and p53 status is still unclear (P<0.05); however, the limited sample size and the low number of events do not allow this finding to be correlated with patient outcome.Availability of tumour tissue before, during and after PCT allows for the possibility of measuring biomarker expression during treatment and, potentially, correlating the observed modifications with outcome. In particular, the tumour-proliferative rate measured as Ki-67, Mib-1 or thymidine labelling index is rapidly and significantly inhibited by hormonal treatment or chemotherapy (vs non-pCR) and biomarker expression and modulation. In this setting, the expression of gene profile measured by DNA microarray offers the opportunity to identify predictive markers of response; this allows us to identify the patients who benefit from the treatment and to spare unnecessary toxicities to those with de novo resistant tumours (Primary chemotherapy can facilitate the development of treatments tailored on the quality of response (pCR In conclusion, we have shown that four courses of preoperative GET are safe and highly active in patients with early-stage breast cancer. This tolerability is worth noting, taking into account that all drugs were administered at nearly full doses, and this regimen can represent an alternative to the sequential administration of myelotoxic drugs. However, in order to exploit all the opportunities offered by preoperative treatments, a coordinated multidisciplinary approach including clinical oncologists, pathologists and molecular biologists is required (


Aspergillus niger from Manipal. The parameters that largely impact enzyme production viz., fermentation time, impeller speed, pH, temperature and nutrient supplements were studied. Optimization of production parameters for production of protease was done by the single-parameter mode. Casein served as substrate and proteolytic activity was estimated using Folin-Ciocalteau method at 660 nm. A maximum yield of 71.3 mg tyrosine/g casein substrate was produced in 96 h on a soluble starch medium at pH 4 in shake flask experiments. Production was carried out on a 3-liter fermenter and 40.7 mg of tyrosine was liberated/g of substrate. The enzyme was extracted with 50% ammonium sulfate and sodium dodecyl sulfate-Polyacrylamide gel electrophoresis showed two bands having mw 45.7 kDa and 38.5 kDa, respectively. The enzyme activity was found to be 147.84 U/ml.Studies were carried out on a paddy soil fungal isolate identified to be a strain of  These e industry. Althoug industry. The pre1) isolated from paddy soil, extract the enzyme and to determine its molecular size using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). This isolate was grown and maintained on potato dextrose agar (PDA) slants at 28° for 10 days and the slants were stored at 4°.The parameters that largely impact enzyme production are fermentation time, impeller speed, pH and fermentation temperature and nutrient supplements. In the present study, an attempt was made to optimize the production parameters for a fungal isolate  were added to the ISP medium no. 9, inoculated and incubated at 28° for 2 weeks.The fungal isolate was subjected to some gross morphological and biochemical studies ilization. Gelatin5-106 colony forming units/ml) was added to an inoculation medium containing glucose (2.0%), yeast extract (1.0%), K2HPO4 (0.1%), KH2PO4 (0.1%), MgSO4 (0.02%) and distilled water q.s. with pH initially adjusted to 7.0 and incubated at 150 rpm at 28°. Production medium consisted of glucose (2.0%), yeast extract (1.0%), K2HPO4 (0.1%), KH2PO4 (0.1%), casein (1.5%) at pH 7.0 was inoculated at 10% level and maintained at 150 rpm on an orbital shaking incubator (Remi) for 7 days at 28°. The amount of tyrosine produced was estimated from 24 h samples by Folin and Ciocalteau method at 660 nm[Spore suspension from a 10-day old slant , fermentation time (studied up to 7 days with 24 h sampling), fermentation temperature (20-40°), initial pH (3-8) and agitation speed (50-250 rpm) were studied. The effect of medium supplements based on carbon , organic nitrogen  and inorganic nitrogen  sources and minor elements magnesium sulphate and calcium carbonate on enzyme production was studied by incorporating the constituent/parameter individually in the production medium.The protocol adopted for optimization of process parameters aimed to evaluate the effect of an individual parameter at a time and to incorporate it at the standard level before optimizing the next parameter. Various process parameters influencing protease production Fermentation was carried out using a 3 l fermenter  set under optimized conditions of substrate concentration, time, temperature, pH, rpm and nutrient supplements with an aeration rate of 1.0 vvm.After complete fermentation, the broth was centrifuged at 10000 rpm for 10 min at 4° to remove mycelium. The supernatant was added with ammonium sulphate to obtain 50% saturation for the precipitation of the enzyme. The precipitated proteins were pelletized by centrifugation at 8000 rpm at 4° for 20 min. The protein pellet was then suspended in 5 ml 0.1 M Tris- HCl buffer pH 7.8 and stored at —20°.1 was determined by SDS-PAGE using 10% acrylamide. The gel was stained with Coomassie brilliant blue solution and destained by washing gel with acetic acid/ methanol solution. After destaining, the destained gels were viewed with the help of Alphaimager (JH BIO) software for determination of molecular weight by comparing with a standard protein marker.The molecular weight of the crude enzyme of isolate PFProtease activity was determined using 0.6% casein substrate at pH 4.0 and 37°. After incubation for 10 min, the reaction was stopped using trichloroacetic acid (TCA) and the amount of liberated amino acid was measured at 660 nm using a tyrosine standard. One unit (U) is defined as the amount of enzyme which yields 1 µg of tyrosine per min at 37° and pH 4.0.A. niger from other species of Aspergillus. Colony color of various Aspergillus species[A. niger group of microorganism. Since the organism appeared promising, experiments were devised to optimize the cultural conditions.The isolated organism was initially white on potato dextrose agar and on sporulation turned black. The reverse color was pale yellow and the colonies showed a compact yellowish white basal felt covered by a dense layer of brownish black conidial heads. The conidiophores originated from the basal foot cell located on supporting hyphae and terminated in a vesicle at the apex . The orgs species is givenInitially the production was studied using casein as substrate. Highest proteolytic activity was seen after 120 h at 1.5% casein concentration  and the et al., have reported that Aspergillus niger acidified the medium and the pH came down to 3 after two days of fermentation[1 was isolated from paddy field soil which has starch residues. Hence, addition of starch can simulate the natural conditions for the isolate. When compared with other nitrogen supplements, peptone was the best organic nitrogen source. Rahman reported that peptone and casein were good inducers of proteases and peptone at 1% level gave best yield[Temperature plays an important role in the synthesis of enzymes. Maximum proteolytic activity was found at temperature of 28° at 120 h. The isolate was mesophilic in nature. The organism produced maximum protease at pH 4. pH had a major effect on the morphology of the organism. At alkaline pH, the organism formed smaller pellets which were rigid, whereas in the case of acidic pH the pellets were bigger in size and fluffy. Donnell est yield.et al. have reported that Aspergillus funiculosus produced maximum protease when supplemented with potassium nitrate[3 (1%), MgSO4 (0.1%) and CaCO3 (0.1%) with pH 4 at, 28°.All the inorganic nitrogen sources showed enhancement in the protease production. Potassium nitrate showed the maximum effect. Shumi m nitrate. There wet al., reported acid protease synthesis by Aspergillus niger (NRRL 1785). Maximum enzyme synthesis is obtained at 96 h of fermentation[After optimizing the production parameters, fermentation was carried out under optimized conditions on a 3 l Bioreactor. The amount of tyrosine liberated/g of substrate was found to be 40.7 mg . AlthougPenicillum expansum and reported the molecular weight of the enzyme to be 20.5 KDa[Streptomyces megasporus in the range of 29 kDa to 90 kDa[The next step was extraction of the enzyme and determination of the enzymic activity. Enzyme was obtained by ammonium sulfate salt precipitation and molecular size was determined by SDS-PAGE . Analysi 20.5 KDa. Patke ato 90 kDa.et al. produced a thermostable protease from a Streptomyces sp. 594 having an activity of 7.2 and 15.5 U/ml in submerged and solid-state fermentations, respectively[1 was found to be 147.84 U/ml.It is difficult to compare the enzyme activity as the conditions employed varied widely in the literature. Azeredo pectively. The enzAsperigillus niger group of microorganisms. The enzyme extracted with ammonium sulfate showed two bands having mol.wts. 45.7 kDa and 38.5 kDa on SDS-PAGE and had an activity of 147.84 U/ml. Further work can be undertaken on enzyme characterization and the study can be extended to the pilot level for possible commercialization.In the present study the cultural conditions for a protease producing fungal organism isolated from paddy soil of Manipal were optimized. Morphological studies indicate that the organism belonged to


Background. The clinical presentation of desmoplastic melanoma is often challenging. We report the experience of the Melanoma Unit of Spedali Civili University Hospital of Brescia, Italy. Method. Study subjects were drawn from 1770 patients with histologica confirmed melanoma. Within this group, desmoplastic melanoma developed in 5 patients. For each diagnosed melanoma, histological characteristics, treatment, and outcomes were evaluated. Results. Of the 5 patients described in this study, 2 were males and 3 females. The average age was 62.4 years ranging from 56 to 68 years. Breslow thickness ranged from 2.1 to 12 mm with a mean thickness of 5.8 mm. Primary treatment of 5 patients included a wide local excision of their primary lesions. Conclusions. Desmoplastic melanoma is a rare neoplasm which clinically may mimic other tumours or cutaneous infiltrate of uncertain significance. The diagnosis is hiastopathological and radical resection is necessary. Desmoplastic melanoma (DM) is a rare variant of malignant melanoma first described by Conley et al. in 1971 as an invasive melanoma composed of spindle cells surrounded by abundant collagen [Study subjects were drawn retrospectively from 1770 patients with histological confirmed melanoma, including melanoma in situ, between January 1, 1984, and January 1, 2009. These patients were followed up by the Melanoma Unit of Spedali Civili University Hospital in Brescia, Italy. All the patients gave an informed consent to be entered into the data-base. A total of 5 patients (0.3%) who had been given a diagnosis of cutaneous desmoplastic melanoma, which was histologically confirmed, were identified . All patIn the period between January 1, 1984, and January 1, 2009 5 patients with cutaneous desmoplastic melanoma were identified. The incidence of desmoplastic melanoma cases in our population was 0.3% (5/1770). Of the 5 patients evaluated, 2 were males and 3 females. All patients were Caucasians. The average age was 62.4 years ranging from 56 to 68 years. Of the 5 documented patients, percentages of Fitzpatrick skin types were as follows: II 60% (3 pz) and III 40% (2 pz). Primary melanomas were found in different body sites: 1 (20%) on the trunk, 2 (40%) on the upper extremity, and 2 (40%) on the lower extremity. None of our 5 cases had a documented family history of melanoma. Breslow thickness ranged from 2.1 to 12 mm with a mean thickness of 5.8 mm. One patient had a lesion with neurotropism (case 5). Primary treatment of 5 patients included wide and deep local excision of their primary lesions. 4 out of 5 patients underwent sentinel lymph node biopsy (SLNB) and no patient was found to have a positive sentinel node. Follow-up ranged from 2 to 113 months, with an average of 49 months, and during follow-up period any patient had disease progression or developed local recurrence.The incidence of desmoplastic melanoma cases in our population was 0.3% 5/1770). Of the 5 patients evaluated, 2 40%) were males and 3 60%) female. This female predominance in sex distribution is not in accordance with previous case series [0% were m/1770. Of0% femaleThere are no dermoscopic criteria for this rare neoplasm probably because dermoscopic examination is not routinely performed before excising a lesion that is often clinically not considered as melanocytic. Debarbieux et al. reported the dermoscopic features for six cases of desmoplastic melanoma. In this short series only half of the cases exhibited one classical feature of a melanocytic lesion while other cases were recognized on the basis of the presence of figures of regression  such as white scar-like and “peppering”, multiple (>4) colours (five out of six), and melanoma-related vascular patterns (five out of six) such as linear-irregular vessels and milky-red areas . The diaThe majority of DMs are larger than 1 mm in thickness at the time of diagnosis, and many tumors measure more than 4 mm. This probably results from the difficulties in clinical diagnosis. In our series, Breslow thickness ranged from 2.1 to 12 mm with a mean thickness of 5.8 mm. The role of SLNB in the DM is not defined as well. Several studies have shown that patients with melanomas of desmoplastic type have a lower frequency of sentinel node positivity than patients with nondesmoplastic melanomas. In view of this, some authors have advocated avoiding SLNB in patients with desmoplastic melanoma –11. 4 ou


Plasmodium falciparum is responsible for the most serious form of the disease with a significant mortality rate.Malaria is the most important human parasitic disease, causing an estimated 500 million cases and more than 1 million deaths annually. Plasmodium falciparum malaria patterns in patients admitted to an Angolan general ICU.To characterize severe Plasmodium falciparum malaria admitted between January 2006 and December 2008 at an Angolan University-affiliated teaching hospital. We collected data on demographics, malaria-related immunity status, clinical presentation, WHO malaria severity criteria, laboratory findings and outcome. Continuous data were analyzed with Students t-test. A P of less than 0.05 was regarded to be significant.A retrospective study based on medical records of adult patients with severe Out of 114 patients admitted with diagnosis of malaria, we enrolled 56 patients. Forty-four (79%) were males. The mean age was 43.0±12.9. Twenty-eight (50%) were nonimmune and only two were adherent to chemoprophylaxis, but reported taking it incorrectly. Fifty-two percent were admitted during the second trimester. The mean APACHE II was 15.4±8.7 with a mean predicted dead rate of 25.9%. The mean SOFA on admission was 7.6±3.6. Fever (82%) followed by headache (41%) and gastrointestinal symptoms (36%) were the most common symptoms on admission and jaundice (61 %) the most common sign. The mean duration of symptoms prior to presentation at the ED was 6.1 ±4.3 days. Malaria diagnosis was confirmed within 24 hours of admission to our hospital In all the cases. Twelve patients presented 2 or more WHO severity major criteria. Forty-one patients were treated with quinine and twelve with artemether. Nineteen patients (34%) required ventilatory support, twenty (36%) intermittent hemodialysis and twelve (21%) vasopressor support. The mean ICU length of stay was 5.5±3.8 days. The 2-day mortality rate and total ICU mortality rate recorded was 10.7% and 37.5%, respectively.In this review, the criteria usually pointed as predictors of a poor outcome on sepsis cases were found to have statistical significance in malaria-related deaths.


CD4 count is a standard measure of immunodeficiency in adults infected with HIV to initiate and monitor highly active antiretroviral therapy; however, it may not be feasible in resource poor countries. There is a need to have another marker of immunodeficiency that is less resource demanding.The objective of this study was to assess the relationship between total lymphocyte count and CD4 count in one of the resource poor countries, Ethiopia.This was a retrospective evaluation. A total of 2019 cases with total lymphocyte and CD4 counts from three hospitals  were included in the study. Pearson correlation, linear regression and Receiver Operating Characteristic (ROC) were used.3 to predict CD4 count < 200 cells/mm3 were 41%, 83.5%, 87.9% and 32.5%, respectively. For subjects aged less than 18 years, these values were 20.2%, 87%, 82% and 27.1%, respectively. A TLC ≤ 1780 cells/mm3 was found to have maximal sensitivity (61%) and specificity (62%) for predicting a CD4 cell count of < 200 cells/mm3. Meanwhile, a TLC ≤ 1885 cells/mm3 would identify only 59% of patients with CD4 count of < 350 cells/mm3. The combined sensitivity and specificity for patients above 40 years of age was greater.For adults, the sensitivity, specificity, positive and negative predictive values of TLC < 1200 cells/mmOur data revealed low sensitivity and specificity of TLC as a surrogate measure for CD4 count. It is estimated that 32.2 million people worldwide were living with HIV at the end of 2007. Meanwhile, 2.1 million lost their lives to AIDS, and 2.5 million became newly infected with HIV in the same year [In Sub-Saharan Africa, the estimated number of adults and children living with the virus at the end of 2007 was 22.5 million, nearly 70% of the global share . Meanwhi3 was not optimal for identifying patients requiring HAART since it showed low sensitivity and specificity to predict CD4 count below 200 cells/mm3 [The rationale for the WHO's recommendation is that most studies concluded a decline in TLC was strongly correlated with a decline in CD4 count, though there were some discrepancies -10. On tells/mm3 . This neA retrospective evaluation was carried out in three hospitals  in the southern part of Ethiopia. Collating data was burdensome as we reviewed 3120 antiretroviral treatment (ART) and pre-ART cards ; 2180 ART and pre ART cards (Arba-Minch); and more than 20 000 non-ART, ART and pre-ART cards (Hossana). The total number of cases with complete data on TLC and CD4 counts was 2019 of which 750, 650 and 619 were from Yirgalem, Arba-Minch and Hossana hospitals, respectively. The year of the data extends from 2003 to 2008. All cases were hospital patients. In all hospitals, TLC and CD4 counts were determined using Cell Dyne automated machine from ABBOTT, USA.βln(1.01) - 1)[β, and expressed as percentage points. Pearson correlation coefficient was also reported.SPSS 15 was used to analyze the data. Linear regression was carried out. As the CD4 and TLC values were log transformed to maintain normality, 100(e.01) - 1) was usedReceiver Operating Characteristic (ROC) was used to determine the cut-off points with best sensitivity and specificity combination. Area under the ROC curve (AUC) was also used to compare the combined sensitivity and specificity among different categories of the study subjects.Ethical clearance was obtained from College of Health Sciences, Hawassa University-Institutional Ethical Review board, and permission was sought from each hospital.3, and 97% had a count of less than 350 cells/mm3. The mean (standard deviation) of CD4 and TLC counts were 145.1 (94.9) cells/mm3 and 1734.1 (880.9) cells/mm3 for subjects aged 18 years and above, and for those under the age of 18 years, the figures were 200.4 (170.6) cells/mm3 and 3700 (942.9) cells/mm3, respectively.A total of 2019 subjects were included in this study, among which 1064 (53%) were females. The mean (standard deviation) age was 32.4 (9.4) years (ranging from 5–65 years), and the majority, 1707 (85%) were below the age of 40 years. Three fourth of the study subjects had CD4 count less than 200 cells/mmr for lnCD4 and lnTLC was .398 (p < .001). The linear regression coefficient (β) was 0.61; that is for each 1% increase in TLC there was 0.61% increase in CD4 count. However, the model was capable of explaining only 16% (coefficient of determination-R2 adjusted) of the variation. Figure 2 = 0.1, r = 0.33, p < 0.001).The correlation coefficient 8 p < .00. The linMean CD4, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for different levels of TLC cut-off values among those who were less than 18 years of age and adults are depicted in table 3 was found to have maximal sensitivity (61%) and specificity (62%) for predicting a CD4 cell count of < 200 cells/mm3. Meanwhile, a TLC ≤ 1885 cells/mm3 would identify only 59% of patients with CD4 count of < 350 cells/mm3 . The combined sensitivity and specificity for patients above 40 years of age was greater since their ROC curve AUC 0.72 was greater as compared to 0.64 of patients ≤ 40 years; the AUC was also slightly greater for female sex (0.66 versus 0.65). For subjects aged less than 18 years the best TLC cut-off was 2050 with sensitivity and specificity of 53.2% and 52.2%, respectively. The ROC curve , as we observed low sensitivity and specificity of TLC as an alternate marker to initiate ART. In our study, the sensitivity and specificity of TLC < 1200 to predict CD4 count < 200 for adults were 41% and 83.5%, and these figures were lower than that reported recently from India, 59% and 94%, respectively . As it wWe recommend further exploration of available data to ameliorate such disparities of sensitivities and specificities of TLC as proxy for CD4 count or else keep on expansion of access to CD4 counter.We also recommend inclusion of white blood cells, red blood cells, haemoglobin, hematocrit and platelets in such analyses and also separate analysis for pregnant women, which we considered as the limitations of this manuscript.The authors declare that they have no competing interests.DD wrote the proposal, secured the funding and organized the data collection. EL analysed and interpreted the data and developed the manuscript. Both authors read and approved the final manuscript.


To determine whether tumour growth is influenced by circadian variations in tumour tissue blood flow, we measured changes in area doubling time of tumours (Sato lung carcinoma) within transparent chambers and changes in tissue blood flow of rat subcutaneous tumour during a light-dark cycle. Rats were subjected to an artificial light-dark cycle with light from 7 a.m. to 7 p.m. Tumour doubling times (TDTs) during the dark and the light spans were 33.5 +/- 11.9 h  and 70.6 +/- 36.9 h  respectively. The former was significantly shorter than the latter (P < 0.001). In addition, the larger the tumour became, the longer was the TDT during the light span (P < 0.05). Tumour tissue blood flow during the night (10 p.m.-4 a.m.) was approximately 1.5 times greater than that during the day (10 a.m.-4 p.m.). The time during which tumours actively grow and that during which tissue blood flow in tumours increases coincided. These results strongly suggest that tumour tissue blood flow is a determining influence on tumour proliferative activity and that tumour growth is influenced by circadian variations in tumour tissue blood flow.


Acute seizures are common among children admitted to hospitals in resource poor countries. However, there is little data on the burden, causes and outcome of neonatal seizures in sub-Saharan Africa. We determined the minimum incidence, aetiology and immediate outcome of seizures among neonates admitted to a rural district hospital in Kenya.st January 2003 to 31st December 2007, we assessed for seizures all neonates (age 0-28 days) admitted to the Kilifi District Hospital, who were resident in a defined, regularly enumerated study area. The population denominator, the number of live births in the community on 1 July 2005 (the study midpoint) was modelled from the census data.From 1P = 0.02). Overall, there was no difference in inpatient case fatality between neonates with and without seizures but, when this outcome was stratified by birth weight, it was significantly higher in neonates ≥ 2.5 kg compared to low birth weight neonates . Up to 13% of the surviving newborn with seizures had neurological abnormalities at discharge.Seizures were reported in 142/1572 (9.0%) of neonatal admissions. The incidence was 39.5 [95% confidence interval (CI) 26.4-56.7] per 1000 live-births and incidence increased with birth weight. The main diagnoses in neonates with seizures were sepsis in 85 (60%), neonatal encephalopathy in 30 (21%) and meningitis in 21 (15%), but only neonatal encephalopathy and bacterial meningitis were independently associated with seizures. Neonates with seizures had a longer hospitalization [median period 7 days - interquartile range (IQR) 4 to10] -compared to 5 days [IQR 3 to 8] for those without seizures, There is a high incidence of neonatal seizures in this area of Kenya and the most important causes are neonatal encephalopathy and meningitis. The high incidence of neonatal seizures may be a reflection of the quality of the perinatal and postnatal care available to the neonates. The first month of life is one of the highest risk periods for seizures  and seizStudies of neonatal seizures in developed nations show that most ictal events are secondary to acute neurological insults such as hypoxic ischaemic encephalopathy (HIE), stroke or infection ,11. In sAlthough neonatal seizures are a common problem in hospitalized neonates in the region ,18,19, f2 is continuously monitored and vital events updated every 4 months. The entire area was mapped using global positioning system and both mapping and population data are linked on-line to the hospital admission data.Since 1998 we have conducted continuous inpatient surveillance aimed at describing the causes and features of common illnesses among Kenyan children in the Kilifi District Hospital ,22. The st January 2003 through to 31st December 2007, since this is the period during which we had reliable data. Consent for use of the data was obtained from the guardian of every individual child at point of admission and the study was approved by Kenyan National Scientific and Ethical Review Board.Standardized clinical and laboratory data is prospectively collected on admission and at discharge or death by clinical and medical officers and directly entered into a computer database. For this analysis, we used data for patients admitted over a 5-year period from 1For the purpose of this study, we defined a neonate as any child admitted aged 28 days or younger . Seizure+<3.0 mmol/L, hyperkalaemia as K+>5.0 mmol/L, hyponatraemia (moderate-severe) as Na+<125 mmol/L and impaired renal function as plasma creatinine >80 μmol/L. Hypoglycaemia was considered in any child with a blood glucose <3 mmol/L. As part of the WHO guidelines, meningitis was considered in all neonates presenting with any one of: drowsiness, lethargy, reduced feeding, high pitched cry, irritability, apneic episodes, a bulging fontanel, unconsciousness or seizures and, where not contraindicated, a lumbar puncture was performed  per 1000 live births per year. The incidence was [13.6 (95% CI 9.6-17.2)] per 1000 live births in the first 48 hrs, [8.5 (95% CI 6.1-12.3)] per 1000 live births in the next 2 to 7 days of life and [18.6 (95% CI 15.4-23.0)] in the rest of the neonatal period. The incidence did not differ by sex . The prevalence of seizures increased with birth weight. Seizures were reported in 3/196(1.5%) of neonates with a birth weight <1.5 kg, in 7/159(4.4%) of those with weights 1.5-<2.0 kg, 27/238(11%) of those with weights 2.00-2.49 kg and 105/967(11%) of those with a birth weight ≥ 2.5 kg, .Two thirds of all neonatal admissions were delivered at home (out-born) of whom 100/1,047(9.6%) had seizures compared to 42/525 (8.0%) born in hospital (χP = 0.34).Forty six of the 142 neonates (32.3%) had seizures within the first 48 hrs of life, 30 (21.1%) had seizures on days 3-7 and in the remaining 66 (46.5%), seizures occurred after the first week of life. Over 50% of seizures occurred within the first week of life and the majority of neonates, 79/142 (56%), had more than one episode within 24 hrs. The median number of seizures on presentation was three [interquartile range [IQR] 2 to 7). However, there was no significant difference between the number of seizures among newborns who died and those discharged alive,  days compared to 4 (IQR 0 to 11) days for those without seizures, 5 days co2 = 1.4, P = 0.24. The proportions of other key laboratory and clinical characteristics of those with and without seizures are as shown in (Table The blood glucose concentration at admission was documented in 1227 (78%) of the resident and incident neonatal admissions. Hypoglycaemia was observed in 277/1227 (22.3%) neonates. The proportions with hypoglycaemia at admission were similar in those with [23/125 (18%)] and without seizures , χOf the clinical and laboratory features  that were associated with seizures on univariable analyses, only fever, irritability, bulging fontanel and isolation of a pathogenic organism in CSF were independently associated with seizures Table .2 = 67, P < 0.001. In addition, among neonates that had an LP, an infectious agent was more likely to be isolated in CSF if the neonate presented with seizures [9/107 (8.4%) compared to 11/569 (1.9%)] of those without seizures, χ2 = 31.4, P < 0.001.The most frequent discharge diagnosis among neonates with seizures was neonatal sepsis 85 (60%), followed by neonatal encephalopathy 30 21%) and neonatal meningitis 21 (15%) but only a diagnosis of neonatal encephalopathy or neonatal meningitis were independently associated with seizures (Table 1% and neStreptococcus pneumoniae (three cases) and non-typhoidal salmonella (two cases). There was one case each of beta haemolytic streptococci, S. aureus, Escherichia coli and Pseudomonas aeroginosa. The diagnosis of meningitis in the other 12 neonates was based on an elevated CSF white cell count ≥ 50 μL.Although sepsis or meningitis was frequently suspected in neonates with seizures, an infective agent in either blood or CSF was isolated in only 16 of the 142 (11.3%) neonates with seizures. Nine out of sixteen of these had isolates grown from CSF. A diagnosis of bacterial meningitis was made in 21 (15%) of the cases with seizures. In nine cases, this was from a positive CSF culture. The commonest isolates from CSF were 2 = 5.7, P = 0.02.A diagnosis of neonatal encephalopathy was made in 227/1572 (14%) of all incident neonatal admissions from the study area. A higher proportions [30/227(13.2%)] of the cases of neonatal encephalopathy had seizures compared to all other diagnosis, [112/1345(8.3%)], χNeonatal encephalopathy was the leading diagnosis in neonates admitted with seizures within the first 48 h of life, 28/46 (60.1%). Only two of this had meningitis and the remaining 16 had neonatal sepsis, three of whom had culture positive sepsis. After the first 48 h, but within the first week of life, neonatal sepsis was the predominant diagnosis. However, meningitis was diagnosed in six cases. Meningitis was also common after the first week of life (13/66 [19.7%]) although neonatal sepsis (43/66 [65.2%]) was still the commonest diagnosis.P = 0.02.Neonates with seizures had a longer hospitalization. The median period of inpatient stay among neonates with seizures was seven (IQR 4 to 10) days compared to five (IQR 3 to 8) for those without seizures, 2 = 125, P < 0.001. There was no difference in case fatality between neonates with and without seizures, χ2 = 0.76, P = 0.38. However, if this was stratified by weight, seizures were associated with higher case fatality in neonates ≥ 2.5 kg compared to low birth weight infants .Three hundred of the 1572 (19.1%) neonates died. Neonates with low admission weight (<2.5 kg) had a higher case fatality 194/593 (33%), compared to those weighing (≥ 2.5 kg) 97/967 (10%), χOf the 32 deaths in neonates with seizures, 12 (38%) were suspected to have sepsis and five (16%), meningitis. However, an infective organism was isolated in only four of these. Of the remaining babies, eight (25%) had neonatal encephalopathy. four had severe neonatal jaundice and three had tetanus. In addition, seven (22%) children who died were hypoglycaemic on admission and 14 (44%) had an abnormal core temperature (<36.0°C or >37.5°C). In total 15 (47%), of the neonates with seizures who died were low birth weight (<2.5 kg) with three (10%) weighing <1.5 kg.2 = 1.78, P = 0.18.On discharge, 14/110 (13%) of the surviving neonates had an abnormal neurological exam. Of the 14, four had hydrocephalus, three were discharged on long-term phenobarbital due to recurrent seizures, another three had a poor sucking reflex and two had spasticity. The remaining two newborns though not classified as normal had subtle undefined neurological abnormality. Follow up through our surveillance system showed that 16/1271 (9.1%) of all neonates died post-discharge and there was no difference between those admitted with or without seizures χChildren living in this rural area of Kenya experience a very high burden of acute seizure disorders. In a previous report, we indicated that the minimum incidence of acute seizures in children 0-13 years of age is as high as 425 per 100,000/year . AlthougThe incidence data we describe is the minimum since not all neonates would have attended the Kilifi District Hospital. In the earlier study, it was estimated that only 20% of children with seizures in the community may have been admitted to hospital . It is aVery few other centres in developing countries have attempted to quantify the burden of neonatal seizures. Previously, based on a small sample of just 43 neonates, we estimated the incidence to be 14.0 per 1000 live births  but the Although neonatal sepsis was a common diagnosis, it was not independently associated with seizures. Importantly, isolation of a pathogenic organism in blood alone was not associated with seizures. The two principal diagnoses associated with seizures were neonatal encephalopathy and meningitis. The increased inpatient case fatality associated with seizures supports previous reports ,5. HowevAlthough debate continues on whether seizures in the neonatal period cause brain damage or are just an epiphenomenon of insults already sustained from the underlying pathology, available evidence suggest that long-term outcome is largely dependent on the cause of the seizure ,5. Our fThe two most common diagnoses associated with neonatal seizures were infections and neonatal encephalopathy. Both conditions are preventable and, using simple public health interventions, it should be possible to reduce the burden of neonatal seizures and neonatal brain injury in the region. Broad measures, such as ensuring safe deliveries, appropriate neonatal resuscitation and prevention and early treatment of infections in the newborn period, may reduce this burden .In this study, we were only able to document seizures that were clinically evident. It is possible that we missed subclinical seizures and, given the fact that electro-clinical dissociation is more common in neonates than in other age groups, the eleIn conclusion, newborns in this rural area of Kenya have a high incidence of seizures and neonates with seizures have a longer hospitalization, increased case fatality in heavier neonates and neurological deficits on discharge. The main causes of seizures are birth-related complications such as neonatal encephalopathy and infections, especially meningitis. Public health interventions aimed at ensuring safe deliveries, appropriate neonatal resuscitation and prevention of infections in the newborn period may help to reduce the high incidence. Prospective studies on the long-term neurological and developmental outcome following neonatal seizures are needed.CSF: cerebral spinal fluid; CI: confidence interval; EPI-DSS: epidemiology and demographic surveillance system; HIE: hypoxic ischaemic encephalopathy; IQR: interquartile range; LP: lumber puncture; OR: odds ratio; WHO: World Health Organization.The authors declare that they have no competing interests. The Wellcome Trust supported this study but played no role in the design, conduct of the study, the analysis and interpretation of data or in the preparation, review and approval of the manuscript.MM designed the study, collected and analysed the data and wrote the draft. AM and SG provided inpatient care and assisted in data analysis. NM and JB supervised clinical care and were involved in writing the draft. CN suggested the study, participated in study design and was involved in data analysis. EB provided the mid-study population data and information on the EPI-DSS. RI designed the study, participated in data collection, analysis and interpretation. All authors critically reviewed the manuscript.Invasive bacterial disease: Positive blood or CSF cultures.Possible sepsis: Presentation with either one of the following:• abnormal temperature (>37.5°C or <35.5°C),• multiple skin pustules,• umbilical redness or pus,• respiratory distress, lethargy, seizures or feeding problems.Meningiti: Presentation with either one of the following:• positive CSF culture,• white cell count of >50/μL in CSF,• positive bacterial antigen test or gram stain.Prematurity: Documentation of gestation age below 37 completed weeks by:• where last monthly period is known and expected date of delivery can be calculated,• acceptable gestation age estimation criteria with:◦ ultrasound,◦ the Dubowitz.• No cry at birth, poor Apgar score (<7) at 5 min.• An accompanying history of feeding problems, restlessness, agitation, hypotonia, hypertonia, seizures and coma, or similar symptoms and signs after excluding other possible.Neonatal jaundice: Significant total plasma bilirubin levels for age, weight and clinical picture of newborn requiring at least phototherapy.Tetanus:• spasms that may be provoked or spontaneous,• trismus.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/8/16/prepub


Objective: Despite the advancement of forensic science, electro-traumas still pose serious challenges. Methods: We have studied the forensic medical documentation from 485 autopsies following electro-trauma over the period 1980–2006, performed at the forensic wards in 6 districts of the country The statistical analysis includes comparison of means and percentages. They are carried out using SPSS Version 11. We accepted statistical significant values of P equals; .05. Results: The incidence of lethal injuries caused by electricity is 1.29 cases per 100000 people per year. The average age of the deceased from electro-trauma is 37.3 years. Men (85%) prevails over women (14.84%). There are 24.32% of the cases that are work-related accidents, and 60.61% of them are domestic. Suicide through electrocution is relatively rare: 7.21%. Homicide has not been registered in our study. Low-voltage injuries (42.06%) are more common than high-voltage ones (30.72%). 62.68% of the lethal cases occur in summer, between June and September. Conclusions: Among the studied cases, electro-trauma occurs at a young age. The victims are typically men. Work-related accidents are more common than domestic ones; injuries by low voltage are observed more frequently than those by high voltage. Suicides are very rare, and not a single case of homicide has been observed in the study. There exists a seasonal variation in incidence of lethal accidents caused by electric current, its peak being during the summer months. Despite the advancement of forensic science, electro-traumas (ET) still pose a seriouschallenge. The aim of the study is to examine the incidence and characterization of ET in some areas of Bulgaria as well as the victims' average age and their distribution by gender.2 (15.23% ± 0.54% of the whole country's territory) and a population of 1 388 277 (17.98% ± 0.06% of the whole population).P = .05.The study has been conducted in 6 districts of the Republic of Bulgaria on a total area of 16 910.31 kmn = 413) prevail over women (14.84% ± 8.21%) (n = 72) .For the 27-year-long period under study, 485 cases of ET have been autopsied, or 1.29 per 100000 people per year, with the population averaging 1 474 945 peoplen = 118) are work-related accidents (0.29 per 100000 people per year on average), and 60.61% ± 5.58% (n = 294) are domestic accidents (0.74 per 100000 population per year on average) .24.32% ± 7.74% cases (n = 35) or (0.09 per 100000 people per year on average). Homicides have not been registered in our article.Suicides by electric current have rarely been observed 7.21% ± 8.56% (n = 204) or (0.51 per 100000 people per year on average) are more common  than those by high voltage 30.72% ± 7.40% (n = 149), which is 0.37 per 100000 people per year on average.Injuries by low voltage Fig  42.06% ±Seasonality is clearly marked in our study Fig . Thus, 3t = 2.8; P < .001). We used the smallest-square method to draw a trend of the electricity-caused injuries in the studied area. The resultant graph , and the most in July: 92 (18.96% ± 8.00%), with significant difference (raph Fig  clearly The analysis of our results shows that the registered average age of the deceased from ET is higher than that in other studies,4Suicides by electric current are relatively rare: 7.21%.We have found that deaths following low voltage injuries are prevalent. In the literature, there is not a unanimous opinion in this respectSimilar to the studies conducted by others authors, We attribute this seasonal trend to the following major factors. The electrical threshold of the myocardium for excitability is decreased with increased environmental temperature and hence the increased number of cases of ventricular fibrillations. When environmental temperature is high, skin moisture is increased and skin resistance is decreased. The summer season presupposes less clothing, and a greater lilihood of direct electrical contact with moist bare skin.Among the studied cases, ET occurs in young age groups. The victims are typically men. Work-related accidents are more common than domestic ones, injuries by low voltage are observed more frequently than those by high voltage. Suicides are very rare, and not a single case of homicide has been observed in our study. The incidence of lethal accidents vary with season, increasing during the summer months.


The outcome of patients with bronchiectasis during and after their stay in the intensive care unit (ICU) has seldom been reported in the literature. Managing these patients in the ICU can be challenging because of the complex nature of their disease. This study aims to identify the in-hospital and long-term outcome of patients with bronchiectasis and respiratory failure (RF) in ICU.A retrospective study was carried out by studying all bronchiectatic patients admitted to the medical ICU for RF over a 10-year period (1995–2004).2  and activity index  were associated with diminished survival in univariate analysis by Cox regression. By long rank test, survival probabilities were significantly low at these strata. Multivariate analysis of Cox proportional hazard model showed that age > 65 years ; activity index ; and inotropic support  were independently associated with reduced survival.The mean (± standard deviation) age of 35 patients was 63.5 ± 11.7 years and APACHE score was 22.3 ± 7.3. The 4-year mortality was 60%. Among the variables observed, age > 65 years (hazard ratio (HR): 4.15; 95% confidence interval (CI): 3.2–5.1), APACHE II score > 24 , intubation , inotropic support , Home-OThe decreased survival of ICU patients was associated with age > 65 years, activity index (bedridden or wheelchair-bound) and use of inotropic support. Bronchiectasis is an abnormal dilatation of the bronchial wall that is generally caused by infection . RecurreThis study was conducted in the medical ICU of King Khalid University Hospital, Riyadh, Saudi Arabia. The charts of all patients who were admitted with the diagnosis of bronchiectasis between January 1996 and January 2004 were reviewed. The study was approved by the Deanship of Scientific Research of King Saud University and the Research Ethics Committee of King Khalid University Hospital, Riyadh, Saudi Arabia. All patients were diagnosed by high-resolution CT scan (HRCT) based on previously reported criteria and had no limitations or withdrawal from therapy . Patient2 > 55 mmHg) and those with unstable haemodynamics were intubated and ventilated with a volume targeted mode. Previous spirometry was measured with standard protocol recommended by the European Respiratory Society . Acidemic patients  score . PremorbThe outcome is defined as survival and discharge from hospital. The charts of those who were successfully discharged were reviewed over a period of 4 years. When the follow-up was lost, the principal investigator contacted the patient's relatives. If the patient was deceased, the exact date of death was recorded.p < 0.05 was considered to be statistically significant.Descriptive statistics (mean and standard deviation) were calculated for all continuous variables. Survival was calculated from the data of patients who either survived up to 4 years or died within 4 years of being discharged from the hospital. Log-rank test was used to compare the survival pattern between the two strata of study variables. Univariate Cox regression was used to identify factors that were significantly associated with lower survival. The Cox proportional hazards model was used to identify the independent predictors associated with reduced survival. Patients who survived to the end of the follow-up period were considered censored. The analysis was done with SPSS pc+ version 10.0 software; 2 therapy. Activity of daily living was identified as bedridden or wheelchair-bound in 24 (68.6%) cases and 8 (22.8%) patients were independent or restricted. CT scans demonstrated that four lobes or more were involved in 12 cases (34.3%) and that at least three lobes were involved for 5 (14.3%) patients.The 35 adults with bronchiectasis were studied retrospectively over 4 years. Mean age was 63.5 ± 11.7; 21 (60%) were females. All patients were in respiratory failure needing assisted ventilation. Cough was prevalent in 29 (82.8%) patients, sputum production was reported in 26 (74.3%), and 10 (29.9%) had haemoptysis. The etiology of bronchiectasis was found in 17 (48.6%) patients based on x-ray findings of old TB and 6 of them had received antituberculous chemotherapy. Twenty-five patients (71.4%) were treated with long-term Home-O1 was 2.01 ± 0.46 L/s. The physiological status of the patients at ICU admission is reported in Table 2 while breathing room air was < 60 mmHg. PaCO2 for 23 patients (65.7%) was > 55 mmHg or pH < 7.30 while on oxygen therapy. Diabetes mellitus was noted in 8 patients (22.8%); hypertension was present in 9 patients (25.7%), 7 patients (20%) had renal disease; liver disease was present in 9 patients (25.7%) and 6 (17%) were smokers.Spirometry results were available for 23 (65.7%) patients. The mean FEV1 for survivors was 2.9 ± 0.6 and 0.9 ± 0.3 L/s for non-survivors. The median follow-up was 240 days . Cumulative mortality was 34.3% (n = 12) in ICU and 60% (n = 21) at 4 years. The causes of in-hospital deaths were: in 6 patients, complications of RF and MODS; in 2, myocardial infarction; in 1, presumed pulmonary embolism; and in 3, undetermined. The risk factors for hospital mortality by univariate analysis are shown in Table 2, and were bedridden or chair-bound. Comparisons by the log-rank tests were significant .NIMV was used for 20 patients (57.1%). Eleven patients (31.4%) required intubation. Twelve (34.3%) died during ICU stay; all these had required intubation. ICU stays were 6.7 ± 7.3 days for survivors (range 1–28 days) and 14.5 ± 15.3 days for non-survivors (range 1–50 days). The mean FEVp-value of 0.5: age (> 65 vs. ≤ 65); APACHE score (> 24 vs. ≤ 24); intubation required (yes/no); inotropic support (yes/no); use of Home-O2 (yes/no); activities of living . Age > 65 , inotropic support , and activity index  were independently associated with reduced survival. The Cox model survival curve for two categories of activity index is provided in Fig. The results of the Cox proportional hazards analysis of factors associated with increased mortality after the ICU admission for RF are shown in Table The studies of long- and short-term outcome of bronchiectasis are scarce in the medical literature -13; the et al. reported the mortality of their patients with bronchiectasis. Nineteen percent died in ICU and the 1-year mortality rate was 40%. Our findings on mortality are worse than they reported because the populations studied were mostly in advanced stages of the disease. Seventy-eight percent of our patients were using home O2 and 57% required NIMV compared to 25% and 27%, respectively, in the DuPont study [In a recent retrospective study, DuPont nt study . Moreovent study .Univariate and multivariate analysis showed that premorbid level of activity was the independent determinant of outcome among our patients. This association has not been examined previously in bronchiectatic patients. Previous studies have shown functional status to be an important predictor of outcome for patients with COPD and RF, especially at 1 year or long term follow-up ,18. Baseet al., who conducted a prospective study of domiciliary nasal intermittent positive pressure ventilation in hypercapnic RF and found that only 20% of patients with bronchiectasis survived after 2 years compared to more favorable results in patients with scoliosis, previous poliomyelitis, or COPD [Our results are also in accordance with the findings of Symonds  or COPD .et al. reviewed the National Hospital Discharge Register in Finland and reported that patients with bronchiectasis had a more favorable outcome than those with COPD, but a less favorable outcome than asthmatics [In another study, Keistinen thmatics . Variatithmatics ,21. It hthmatics . Selectithmatics . Moreovep = 0.03) was associated with diminished survival in univariate analysis by lot regression. Moreover, the mean FEV1 for survivors was 2.9 ± 6 compared to 0.9 ± 0.3 for non-survivors.Age was a statistically significant determination of 1-year and 4-year survival in this study. The association of age with long-term mortality risk could be modulated by other diseases and the severity of the acute illness. The abnormal physiology and the complications that develop during ICU stay strongly influence the patient's outcome. APACHE II score has been tried as a model of predictive survival in general ICU, but has not previously been evaluated in bronchiectatic patients. In this study, APACHE II score > 24  declare that they have no competing interests.AHA – principal author and investigator. He initiated the study. He prepared the study proposal, recruited study patients and supervised the entire conduct of the study from beginning to preparation and submission of the manuscript.MM – co-investigator. He helped in the recruitment of patients. He was instrumental in the collection of data, data entry, and literature review. Helped in the preparation and review of the manuscript.SJB – co-investigator. He was instrumental in the review of the collected data. Together with the principal investigator and co-investigators, they ensured completeness of the data. Helped in the preparation and review of the manuscript.SAS – reviewed the data and did the statistical analysis using appropriate statistical methods.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Twelve patients had a well-differentiated and 41 a poorly differentiated neuroendocrine tumour. Toxicity of treatment was assessed in 50 patients and efficacy in 52 patients. Among the 11 patients with a well-differentiated tumour evaluable for tumoural response, only one (9.4%) had a partial response for 8.5 months. Forty-one patients with a poorly differentiated tumour showed an objective response rate of 41.5% ; the median duration of response was 9.2 months, the median overall survival 15 months and the median progression-free survival 8.9 months. Haematological grade 3–4 toxicity was observed in 60% of the cases with one treatment-related death, digestive grade 3–4 toxicity in 40% and grade 3 alopecia was constant. No severe renal, hearing and neurological toxicities were observed . We confirm that poorly differentiated neuroendocrine tumours are chemosensitive to the etoposide plus cisplatin combination. However, the prognosis remains poor with a 2-year survival lower than 20% confirming that new therapeutic strategies have to be developed. © 1999 Cancer Research CampaignThe purpose of this study was to evaluate by a retrospective analysis of 53 patients the efficacy of chemotherapy combining etoposide and cisplatin in the treatment of neuroendocrine tumours. The regimen was a combination of etoposide 100 mg m


To evaluate the vascular response at 9 months after zotarolimus-eluting stent  implantation using optical coherence tomography (OCT). These findings were compared with those after implantation of a sirolimus-eluting stent .Cross-sectional observational study with prospective OCT registry.Nine months after ZES or SES implantation.A total of 68 patients (32 ZES and 36 SES) underwent OCT at 9 months after stent implantation. The neointima hyperplasia (NIH) thickness inside each strut and percentage of NIH area at every 1 mm cross section were measured.The degree of neointimal coverage and the prevalence of malapposition at 9 months after ZES and SES implantation using OCT.The mean (SD) NIH thickness (251.2 (110.0) μm vs 85.5 (53.3) μm, p<0.001) and percentage of NIH area (27.9 (9.1)% vs 11.2 (7.1)%, p<0.001) were significantly greater in ZES than in SES. The prevalence of uncovered strut as well as malapposed strut was significantly lower in ZES than in SES . Thrombus was not observed in ZES .Neointimal coverage in ZES was almost complete and malapposition was very rare at 9-months’ follow-up. Although in-stent restenosis (ISR) was remarkably reduced after introduction of the drug-eluting stent (DES), excessive inhibition of neointima formation caused delayed arterial healing with incomplete endothelialisation over the stent strut.Intravascular optical coherence tomography (OCT) can identify thin layers of neointima and malapposition with its high resolution (10–20 μm).a) de novo lesion with >50% diameter stenosis, which was related to myocardial ischaemia; (b) native vessel size of 2.5–3.5 mm in diameter; (c) stable angina or acute coronary syndrome (ACS) including ST elevation myocardial infarction; (d) non-overlapping stents. The exclusion criteria included: (a) significant left main coronary artery disease; (b) congestive heart failure or low ejection fraction (⩽35%); (c) renal insufficiency with baseline creatinine ⩾2.0 mg/dl; (d) lesions unsuitable for OCT with occlusive technique . The choice of DES (ZES or SES) was made according to the operator’s preference. The OCT was performed in 68 patients (32 ZES and 36 SES) during follow-up angiography at 9±2 months. Among 179 patients, we performed a follow-up angiography in 120 patients between 7 and 11 months. Among 120 patients, OCT was performed in only 80 patients because of difficulties and refusal to undergo the OCT procedure. Additionally, 12 stents were not completely evaluated for the whole stent length, and, therefore, we excluded 12 stents after OCT evaluation. The study protocol was approved by the Institutional Review Board of Yonsei University College of Medicine and written consent was obtained from all patients.One hundred and seventy-nine patients treated with ZES  or SES  (90 SES and 89 ZES) who fulfilled inclusion and exclusion criteria were consecutively enrolled in this study between November 2006 and October 2007. The inclusion criteria for this study were: (Quantitative coronary angiography (QCA) was performed offline using a quantitative coronary angiography analysis system  by a single person blinded to patients’ information. Minimal luminal diameter (MLD) of treated coronary segments, reference vessel diameter (RVD), percentage diameter stenosis and lesion length on the baseline angiogram were determined in the view that demonstrated lesions to be most severe and not foreshortened. Post-procedure and follow-up angiograms were evaluated in the same view.An OCT system  and a 0.014 inch wire-type imaging catheter  were used in this study. A 6 or 7 Fr guiding catheter was introduced into the coronary artery by femoral or radial approach. When the image wire had been positioned through the occlusion balloon distal to the stent, the occlusion balloon  was inflated to 0.4–0.6 atm and Ringer’s lactate was infused at 0.5–1.0 ml/s. The image wire was pulled distal to proximal at a speed of 1 mm/s, and continuous images were stored digitally for subsequent analysis. Cross-sectional OCT images were analysed at 1 mm intervals (every 15 frames).Among 1535 image sections, 1473 image sections 96.0%) were analysable in this study 696/710 98.0%) in ZES and 777/825 (94.2%) in SES). Parameters were calculated and defined as follows: distances between the endoluminal surface of neointima and stent strut were measured with a measurement line as perpendicular as possible to the neointima and strut..0% in ZE.0% in ZE6.0% wereA cross section with uncovered strut was defined if one or more stent struts was uncovered on cross section and a cross section with uncovered strut ratio >0.3 was defined when the ratio of uncovered struts to total stent struts per cross section was more than 0.3.All patients received dual antiplatelet therapy  for at least 9 months. Death, non-fatal myocardial infarction and LST were evaluated for 9 months.2 test and Fisher exact test while the Student t test was used to compare continuous variables. If the distributions were skewed, a non-parametric test was used. Because of the hierarchical structure of data for all struts across stents and patients, multilevel logistic analysis was applied for uncovered and malapposed struts as the outcome variable to control for the random and fixed effects of the strut, lesion and patient characteristics. At the lesion level, lesion type , stent type (ZES vs SES), stent length, stent diameter, RVD, MLD and maximum inflation pressure were considered. At the patient level, age, sex, ACS and diabetes mellitus were considered.Inter- and intraobserver variability in measurements of distance and area were assessed by evaluation of 20 random cross-sectional images by two independent readers and by the same reader at two separate time points, respectively. Variations in measurements were calculated using linear mixed models (one- and two-way). Results are expressed as mean (SD) or number (%). Comparisons of categorical variables were made using a χAll analyses were performed using Statistical Analysis Software (SAS) 9.1.3. . A p value <0.05 was considered statistically significant.The mean (SD) stent diameter was larger in ZES than SES (3.1 (0.3) mm vs 2.9 (0.3) mm, p = 0.004), but stent length and lesion type were similar in both groups . MaximalPreintervention QCA data were similar between the two groups (mean (SD) RVD: 2.9 (0.3) mm in ZES vs 2.8 (0.4) mm in SES, p = 0.25 and MLD: 0.8 (0.5) mm in ZES vs 0.7 (0.4) mm in SES, p = 0.50). Although acute gain was similar between the groups, both diameter stenosis and late loss at 9 months after implantation were significantly greater in ZES .2 vs 6.6 (1.6) mm2, respectively, p<0.001), which was consistent with QCA. Additionally, NIH area (2.2 (0.8) mm2 vs 0.7 (0.4) mm2, p<0.001) and percentage of NIH area (27.9 (9.1)% vs 11.2 (7.1)%, p<0.001) were greater in ZES than in SES. The intraobserver correlation coefficient of neointimal thickness or distance and area between variability of a single observer was 0.981 (95% CI 0.975 to 0.985) and 0.997 (95% CI 0.993 to 0.999) using a one-way mixed model, in which patient effects are random. The interobserver correlation coefficient of neointimal thickness or distance and area between the variability of two observers using a two-way mixed model, in which patient effects were random and observers’ effects were fixed, was 0.982 (95% CI 0.977 to 0.986) and 0.993 (95% CI 0.982 to 0.997).In a comparison of neointima over the stent struts of ZES and SES, it was found that most stent struts of ZES were covered with neointima. However, >10% of stent struts in SES were not covered with neointima (uncovered stent struts of ZES vs SES: 28/8497 (0.3%) vs 991/8066 (12.3%), p<0.001, NIH pattern and the mean neointima thickness were quite different between the two stent groups . The thiFollow-up angiography at 9 months was available in 120 patients (62 ZES and 58 SES). ISR occurred in eight and five patients in the ZES and SES group, respectively. But, OCT examination was possible in only four patients treated with SES among 13 patients with ISR. In both groups there were no deaths, non-fatal myocardial infarction and LST during the 9 months.Our study showed that neointimal coverage of stent struts was almost complete with a more homogeneous pattern in ZES at 9 months. Uncovered and malapposed struts were frequently observed and the NIH pattern was more heterogeneous in SES.A previous pathological report demonstrated an association between the lack of neointimal coverage in stent struts and thrombus formation.Several imaging modalities can be used to study neointimal coverage of stents. IVUS has been widely used to detect NIH after stent implantation, but it has a critical limitation in resolution that can only differentiate neointima thicker than 100 μm. Therefore, it is impossible to evaluate precisely neointimal coverage in DES because previous studies, including this study, have shown that a considerable portion (40%) of neointima is <100 μm in thickness.et al reported the rates of neointimal coverage were 50.2% in ZES and 10.5% in SES at 8 months but other OCT data for SES showed 85–91% of neointimal coverage between 3 and 6 months.et al also demonstrated that both ZES and SES had over 90% of neointimal coverage at 6 months.Recently, OCT has been introduced as a high-resolution imaging modality with 10–20 μm of axial resolution.This study showed that neointima covered almost all of the stent struts and was evenly distributed in ZES compared with that in SES (99.7% in ZES vs 87.7% in SES). This finding was similar to previous angioscopy findings between SES and ZES and compatible with those of BMS.A previous pathology study showed that non-uniform neointimal coverage with DES, which was indicated by the number of uncovered struts for each cross section, markedly increased stent thrombosis risk, and lack of neointimal coverage was associated with thrombus formation.3Malapposition is another possible predictor of stent thrombosis, though there has been some disagreement in the literature.This study had several limitations. First, it was a non-randomised study and the initial OCT images immediately after implantation were not available. Second, this study had a relatively small population who had a follow-up angiography and OCT, which might have resulted in selection bias. However, the number of stent struts (more than 15 000 struts) was enough to evaluate neointima or malapposition. Third, the quality as well as quantity of NIH might be important to prevent thrombus formation. We could not evaluate the quality of neointima in this study.ZES, compared with SES, showed an almost complete homogeneous neointimal coverage of stent struts and low rate of malapposition at 9 months after implantation.


Ascitic fluid infection (AFI) in cirrhotic patients has a high morbidity and mortality. It has two variants namely, spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites (CNNA). The aim of this study was to determine the outcome in cirrhotic patients with culture positive (SBP) and culture negative neutrocytic ascites.We analyzed 675 consecutive hepatitis B and/or C related cirrhosis patients with ascites admitted in our hospital from November 2005 to December 2007. Of these, 187 patients had AFI; clinical and laboratory parameters of these patients including causes of cirrhosis, Child Turcotte Pugh (CTP) score were recorded.9/L) as compared to CNNA (132 ± 91 × 109/L), p = 0.005. We found a high creatinine (mg/dl) (1.95 ± 1.0 vs. 1.44 ± 0.85), (p = 0.003) and high prothrombin time (PT) in seconds (24.8 ± 6.6 vs. 22.4 ± 7.2) (p = 0.04) in SBP as compared to CNNA. More patients with SBP  had blood culture positivity as compare to CNNA , p = 0.002. Escherichia. Coli was the commonest organism in blood culture in 15/28 (53.5%) patients. SBP group had a higher mortality  as compared to CNNA , p = 0.003. On multiple logistic regression analysis, creatinine >1.1 mg/dl and positive blood culture were the independent predictors of mortality in patients with SBP.Out of 187 patients with AFI, 44 (23.5%) had SBP while 143 (76.4%) had CNNA. Hepatitis C virus (HCV) infection was the most common cause of cirrhosis in 139 (74.3%) patients. Patients with SBP had high CTP score as compared to CNNA (12.52 ± 1.45 vs. 11.44 ± 1.66); p < 0.001. Platelets count was low in patients with SBP (101 ± 53 × 10Patients with SBP have a higher mortality than CNNA. Independent predictors of mortality in SBP are raised serum creatinine and a positive blood culture. Two variants of AFI have been described in medical literature, 1) Spontaneous bacterial peritonitis (SBP) with polymorph nuclear (PMN) count >250/mm3 in the absence of evidence of abdominal infection is also a form of AFI even though the ascitic culture is negative [The first description of SBP did not include those patients who had a negative ascitic fluid culture. The term CNNA was proposed in 1984  and is cSBP is a serious complication of end-stage liver disease, with a very high recurrence rate of up to 70% at 1 yr -7, and iThere are few studies addressing the outcome in cirrhotic patients with AFI ,4,9. OneThere is a paucity of literature comparing the outcome in patients based on culture results, and factors predicting poor prognosis in cirrhotic patients with ascitic fluid infection. The available literature has included very limited number of patients with the two variants AFI and shows low mortality in CNNA as compared to SBP . MoreoveWe studied the outcome in the two variants of AFI in a large cohort of patients with viral causes of cirrhosis including hepatitis B and/or hepatitis C in a tertiary care University Hospital setting.We analyzed 675 consecutive patients with viral causes of cirrhosis along with ascites admitted at The Aga Khan University Hospital from November 2005 to December 2007. The medical records of patients admitted with symptoms and signs of ascitic fluid infection such as fever, abdominal pain and those with asymptomatic infection were retrieved. The data of their age, gender, clinical features, complications such as hepatic encephalopathy, upper GI bleed, hepatocellular carcinoma, etc was collected along with laboratory data and the Child Turcotte Pugh (CTP) score was calculated for all patients. All patients had liver cirrhosis diagnosed on clinical, hematological and biochemical laboratory parameters along with ultrasonological findings. 187 patients with ascitic fluid infections met the criteria in the form of either SBP or CNNA and they were included in the study. Only patients who had first episode of either SBP or CNNA were included in this study. Patients with secondary bacterial peritonitis, non-cirrhotics causes of ascites such as tuberculosis or malignancy were excluded. Those with cirrhosis and ascites who received systemic antibiotics within 30 days for any other infection (s) were also excluded from the study. Patients with cirrhosis due to causes other than hepatitis B, C or D viral infections were also excluded.Diagnostic paracentesis was performed on the bed side by sterile method with a 21 G needle attached to 20 cc syringe, and then collected into Ethylene Diamine Tetra Acetate (EDTA) tube and analyzed within 3 hours of extraction. Ascitic fluid was then centrifuged in laboratory for 3 minutes for detailed report including total proteins, total and differential leukocyte count. Smear was performed and stained with Geimsa. At the same time 10 cc of ascitic fluid (5 cc in each bottle) was inoculated in aerobic and anaerobic blood culture bottles  containing Trypticase foy broth and processed according to manufacture's instructions and were observed for 1 month.3.Similarly, blood cultures were also drawn in aerobic and anaerobic blood culture bottles, before starting antibiotics. All patients were treated with ceftriaxone 2 grams once daily and it was changed to appropriate antibiotic (s) based on less than 50% improvement in PMN count in the repeat ascitic fluid detailed report after 48 hours or culture sensitivity results of initial ascitic fluid. Recovery from the AFI was assessed on the basis of decrease in ascitic fluid PMN count to < 250/mmThis study is approved by the Ethics Review Committee (ERC) of Aga Khan University Hospital.© SPSS; 1989–02). A descriptive analysis was performed for clinical features and results are presented as mean ± standard deviation for quantitative variables and numbers (percentages) for qualitative variables. χ2 test and Fisher's exact test were used for categorical variables, while the independent sample t-test was applied for numerical variables. We used a one-way analysis of variance (ANOVA) for determining any statistical difference amongst the subgroups. Variables found to be statistically significant in the univariate analysis (p ≤ 0.25) were included in a multivariate stepwise logistic regression model. The model was constructed to identify independent predictors of mortality in patients with SBP and to obtain the odds ratio.Statistical analysis was performed using the Statistical package for social science SPSS  patients with AFI were included for analysis. There were 44 (23.5%) patients who had SBP while 143 (76.4%) had CNNA  as compared to CNNA (132 ± 91 × 109/L), p-value = 0.005; similarly, SBP group had a high creatinine level (1.95 ± 1.0 mg/dl) as compared to CNNA (1.44 ± 0.85 mg/dl), p-value = 0.003. Ascitic fluid WBC counts were not different in the two groups, while blood cultures were significantly positive in patients with SBP. Table Majority of hematological and biochemical laboratory tests including hemoglobin, white blood cells (WBC) counts, and liver function tests were similar in the two groups. There were significantly low levels of platelets in SBP group (101 ± 53 × 10Hepatitis C virus (HCV) infection was the most common underlying cause of cirrhosis in 139 (74.3%) followed by hepatitis B virus (HBV) infection in 43 (22.9%); out of these 43 patients 12 (6.4%) had concomitant hepatitis D virus infection. Moreover, 5 (2.6%) patients had concomitant HBV and HCV infection causing cirrhosis.Out of 187 patients with AFI, 44 23.5%) had culture positive ascitic fluid cultures i.e., SBP; of these 32 (72.7%) patients had gram negative bacterial infection, while rest of 12 (27.2%) had gram positive infection. Escherichia. Coli (E. Coli) being the most common organism isolated from 27 (61.3%) patients. Table .5% had cOverall 28/187 (14.9%) patients had positive blood culture results. The yield of culture was higher in SBP group  as compared to CNNA group , p-value = 0.002. There were 17 (60.7%) gram negative and 11 (39.2%) gram positive bacterial infection. Among the gram-negative organisms, E. coli was the most common isolated from blood culture in 15/28 (53.5%) patients.All patients were started on intravenous ceftriaxone 2 grams once daily, after drawing ascitic and blood cultures. Intravenous salt poor albumin (25%), 100 ml twice a day for 5 days was given to all patients with a creatinine level of >1.5 mg/dl as per the protocol of our Gastroenterology Section. Out of 44 patients with SBP 13 were resistant to first line antibiotic; 7/32 (22%) were resistant in gram negative group while 6/12 (50%) in gram positive infection group. Gram negative resistant organisms were sensitive to other beta-lactam antibiotics; five of these patients were treated with piperacillin tazobactam and 2 received imepenam (carbepenam group) as per treating physician's decision. Similarly, vancomycin was given in 6 patients in whom ascitic culture was positive for Staphylococcus and Enterococcus species. Out of these 13 patients with resistant organism 8 died due to delay in start of appropriate antibiotics. There was 11/44 (25%) in-hospital deaths in SBP group of patients as compared to 12/143 (8.4%) in CNNA group, p-value = 0.003; the causes of death in SBP group were AFI and sepsis in 8 patients and PSE, hematemesis and seizures in 1 patient each. Whereas in CNNA 6 patients died of AFI and sepsis and 2 patients each in PSE, seizures and pneumoniaSurvival curve of patients with SBP and CNNA group of ascitic fluid infection is shown in Figure Predictors of mortality in patients with SBP variant of ascitic fluid infection, on univariate analysis were, presence of PSE, raised creatinine, low platelets counts, increased PT. Furthermore, blood culture positive results were also significant on univariate analysis for mortality in patients with SBP. We analyzed all these factors along with those of a p-value of <0.25 for finding the independent predictors of mortality by logistic regression technique. After multiple logistic regression analysis we found that a creatinine of >1.1 mg/dl and positive blood culture were the independent predictors of mortality in patients with SBP. Table 4This is one of the largest reports of hepatitis B and C virus related cirrhotic patients with ascitic fluid infection. The incidence of AFI, including SBP and CNNA was found to be around 28%. We found that mortality is higher in patients with SBP 11/44 (25%) as compared to CNNA 12/143 (8.4%) in our series. We also found that the independent predictors of mortality in SBP were raised creatinine (> 1.1 mg/dl) along with blood culture positivity.SBP and CNNA are both considered serious complications of advanced liver cirrhosis . ReporteRunyon and Hoefs in 1984  studied . We were unable to find any reason for this low yield accept that the amount of ascitic fluid inoculated was 5 cc in each bottle as compared to few studies where 10 cc was inoculated [In our report the rate of ascitic fluid bacterial growth was less 23%) as compared to other reports, where it ranges from 50 to 71% % as comp. Use of oculated ,11.E. coli was the most common organism found in two thirds of patients with SBP, monomicrobial gram-negative organism was recovered in 32 (72.7%) patients and E. coli representing more than two thirds, which is similar to other studies ,11. InteOver all 23/187 (12.2%) patients with AFI died in our report; out of this majority, belonged to SBP group. The possible explanation for worse prognosis in SBP group could be advanced liver cirrhosis in this group as evidenced by CTP score and more renal impairment (Table In conclusion ascitic fluid infection is a serious and life threatening complication of liver cirrhosis. SBP is associated with a higher mortality than CNNA. Patients with raised serum creatinine levels and positive blood cultures have poor prognosis, and they should be treated with greater vigilance. In the new era advanced culture methods with high and early yield can facilitate a prompt and accurate initiation of antibiotic therapy.The authors declare that they have no competing interests.LK and KM conceived the idea and drafted the protocol. LK supervised the data collection and statistical analysis; she wrote the first draft and revised manuscript under the supervision of KM. KM revised and advised for modifications in the statistical analysis and manuscript. USA and AWA were mainly involved in data collection and entered into SPSS software; they also contributed in the first draft of manuscript. WJ contributed in conception of study and participated in design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: