BackgroundSpondylolisthesis is characterized by the slipping of one vertebra, compared with the underlying one, due to structural and degenerative changes. Its origin is multifactorial which includes disc degeneration, facet joint anatomic orientation, iliolumbar configuration, and ligament hyperlaxity. The most common operative treatment is decompression and may require an individualized surgical plan. However, only decompression may progress the slippage which can result in pain or recurrence of neurological complaints. Therefore, lumbar fusion and fixation are considered appropriate to stabilise the spine and prevent delayed deterioration. The aim of our study was to find out the outcome of posterior decompression, with reduction and fixation of lumbosacral spondylolisthesis by Oswestry Disability Index (ODI) to improve further our results.MethodsThis study was conducted from July 2013 to February 2017 including 94 patients with lumbosacral spondylolisthesis. The Meyerding classification was used to grade the extent of vertebral slippage. The assessment was done using the ODI.ResultsThere were 50 (53.19%) males and 54 (46.80%) females with a mean age of 44 years ± 10.49 SD. Backache was present in all patients and claudication in 85 (90.42%) patients. There were 10 (10.63%) patients with spondylolisthesis at L3-L4, 36 (38.29%) at L5-S1 and 48 patients (51.06%) at L4-L5 level. In 48 patients with L4-L5 level, 38 (79.16%) were in grade II while six (12.5%) were in grade III. According to the preoperative ODI score, 38 patients were placed in moderate disability, 42 patients were severely disabled while four patients were disabled.Good outcome was achieved in a total of 79 (84.04%) patients. In 40 (42.55%) patients, with complete reduction, the good outcome achieved in 35 (83.33%) while in 22 (23.40%) patients there was no reduction and a good outcome was achieved in 17 (77.27%) patients. In 38 (40.42%) patients with moderate disability, 32 (84.04%) patients had a good outcome. Post-operative cerebrospinal fluid (CSF) leak occurred in five (5.31%) and wound infection in seven (7.44%) patients while there was no mortality.ConclusionReduction with decompression can have a good outcome in spondylolisthesis, and ODI should be used as a predictor of outcome. It also shows that proper decompression is required and not a complete reduction. Spondylolisthesis is characterized by the slipping of one vertebra, compared with the underlying one, due to structural and degenerative changes . Its diaThe most common operative treatment is decompression and may require an individualized surgical plan . HoweverThis descriptive study was conducted between July 2013 and February 2017 with the consent of the patients and approval of the institutional review board with a follow-up of six months to three years. There was a total of 94 patients with lumbosacral spondylolisthesis. This included patients of either sex, aged between 15 and 70 years, grade I spondylolisthesis with disc herniation and grade II and above. Those with traumatic or pathological aetiology, below the age of 15 years, above the age of 70 years, grade I without disc herniation, previously operated, and those with associated cervical or knee problems were excluded. After taking history and doing a clinical examination, a preoperative radiological assessment was done by using X-rays anterioposterior and lateral views, MRI and CT scan with the 3-D reconstruction of the lumbosacral spine. The Meyerding classification was used to grade the extent of vertebral slippage, showing grade I with 0-25% slippage; grade II with 25-50% slippage; grade III with 50-75% slippage and grade IV with 75-100% slippage. The assessment was done by using ODI score which has a questionnaire including 10 components. The score obtained by patients was recorded, and ODI score was calculated as, score achieved by the patient divided by the total possible score, multiplied by 100. According to ODI score, 0% to 20% is a minimal disability, and patients can cope with living activity, 21%-40% is moderate disability and patients are with pain in daily activity and are disabled from work. In severe impairment with score 41%-60%, everyday activity of patients is affected, and they need detailed investigations, while 61%-80% is crippling back pain in which all aspects of life are pinged and with a score of 81%-100%, patients are bed-bound. All patients underwent a surgical procedure in a prone position. We did a decompressive laminectomy, transpedicular screws insertion with rods, reduction and posterolateral grafting from the iliac bone. Discectomy was done in all cases of grade I with disc herniation and drain was inserted in all patient for 24 hours. Postoperatively, X-rays were taken, and ODI score was calculated in follow-up, and it was labelled as good when there was an improvement of more than 20 score and fair when improvement was between 10 and 20 score, and it was poor when improvement was less than 10 score.Data were analysed by using SPSS, Version 22 . Percentage and frequency were detected, chi-square test and paired t-test were applied, and p-value of less than 0.05 was considered significant.Majority of patients were male, 50 53.19%), as compared to females, 44 (46.80%). Age ranged from 15 to 70 years with a mean 44 years ± 10.49 SD. Backache was present in all patients, claudication in 85 patients (90.42%), straight leg raise (SLR) restricted in 40 patients (42.55%), lumbar extension painful in 87 patients (92.55%). According to the preoperative ODI score, 38 (40.42%) patients (average ODI score 32.63) were placed in moderate disability, 52 (55.31%) patients (ODI score 52.58%) were in severe disability while four (4.25%) patients (ODI score 6.7%) were crippled, as shown in Table 9%, as coThere were 10 (10.63%) patients with spondylolisthesis at level L3-L4, 36 38.29%) patients at L5-S1 and 48 (51.06%) patients at L4-L5 level. In 48 patients with L4-L5 level, 38 (79.16%) were in grade II while six (12.5%) were in grade III as shown in Table 9% patienThere were 10 patients 10.63%) in grade I and 70 patients 74.46%) in grade II. In patients with grade I spondylolisthesis, the complete reduction was achieved in eight patients (80%). However, in 70 patients (74.46%) with grade II, the complete reduction was achieved in 30 (42.85%) patients while there was no reduction in 20 patients (28.57%), as shown in Table % in grad.46% in gPost-operative cerebrospinal fluid (CSF) leak occurred in five (5.31%) patients, wound infection in seven (7.44%) patients, urinary incontinence in one patient (1.06%), partial foot drop in one (1.06%) patient, deep venous thrombosis in four (4.25%) patients and paralytic ileus in three (3.19%) patients. There was no mortality noted in our series of patients. All complications improved with conservative treatment.Spondylolisthesis, a complex and challenging multifactorial condition, shows forwards slippage of one vertebra over another. It can occur at any age and one study shows the average age of 42 years . It may Patients complain of pain that worsens with activity, usually exacerbated by repetitive extension, rotation, and return from a flexed position, while relieved by rest. In some cases, patients may report radicular symptoms in one or both legs . Thus paRadiologically, spondylolisthesis can be described according to its degree of severity, with one commonly used description being grade-I least advanced, and grade-V being most advanced. Surgical indications include progressive slip, significant lumbosacral kyphotic deformity, neurologic deficit, intractable back pain, and refractory radicular pain ,11.In one study, there were 29 patients with grade II out of 36 comprising 80.55% and in our study grade II was in 70 patients comprising 74.55% . The sliTreatment of spondylolisthesis involves both surgical and non-surgical options. Non-surgical treatment is focused on reducing pain, facilitating fracture healing, and preventing any additional vertebral mal-alignment. These non-surgical options can be used alone or in various combinations . SurgicaAn assessment of the history of surgeries for spondylolisthesis indicates that most surgeons tend to perform spinal procedures through a posterior approach due to more familiarity with this approach, decreased risk of injury to great vessels or vital organs, greater ease of revision operations, ability to operate on multi-levels, and no need for assistance from a general or vascular surgeon . Thus thThere are different scoring systems like ODI, VAS, and Beaujon functional score, etc. but we have used ODI. The ODI is used by clinicians and researchers to quantify disability for low back pain. It is thus currently considered as the gold standard for measuring the degree of disability and estimating the quality of life in a person with low back pain . HoweverRegarding this particular study, while keeping all these parameters in mind, we used this index to measure the symptomatic outcome in our series of patients after surgery. The results indicated good results when assessed by this score after surgery similar to other studies. According to the pre-operative ODI score was 53.7 (±13.1) which improved to 22.5 SD 15.5 at two years follow-up . The aveIn spondylolisthesis surgery, decompression and reduction both are important, but reduction shows no correlation to the clinical outcome . In our Like other surgeries, complication can be expected, and there are chances of CSF leak, infection implant failure and neurological deterioration. The long duration of surgery can be a risk factor for superficial or deep wound infection . This coIn a meta-analysis, authors concluded that fusion with decompression surgery is a better technique when compared to decompression alone for spinal stenosis in terms of the ODI and the VAS for pain. Decompression with fusion is a 3.5-time better surgical technique than decompression alone for spinal stenosis .Spondylolisthesis is a significant spinal problem, and reduction with decompression can have a good outcome, and ODI should be used as a predictor of outcome. It also shows that proper decompression is required and not a complete reduction.


Uveal melanoma (UM) is highly refractory to treatment with dismal prognosis in advanced stages. The value of the combined checkpoint blockade with CTLA-4 and PD-1 inhibition in metastatic UM is currently unclear.Patients with metastatic or unresectable UM treated with ipilimumab in combination with a PD-1 inhibitor were collected from 16 German skin cancer centers. Patient records of 64 cases were analyzed for response, progression-free survival (PFS), overall survival (OS), and safety. Clinical parameters and serum biomarkers associated with OS and treatment response were determined with Cox regression modelling and logistic regression.p = 0.007).The best overall response rate to combined checkpoint blockade was 15.6% with 3.1 and 12.5% complete and partial response, respectively. The median duration of response was 25.5 months (range 9.0–65.0). Stable disease was achieved in 21.9%, resulting in a disease control rate of 37.5% with a median duration of the clinical benefit of 28.0 months (range 7.0–65.0). The median PFS was 3.0 months (95% CI 2.4–3.6). The median OS was estimated to 16.1 months (95% CI 12.9–19.3). Regarding safety, 39.1% of treated patients experienced a severe, treatment-related adverse event according to the CTCAE criteria . The most common toxicities were colitis (20.3%), hepatitis (20.3%), thyreoiditis (15.6%), and hypophysitis (7.8%). A poor ECOG performance status was an independent risk factor for decreased OS (The tolerability of the combined checkpoint blockade in UM may possibly be better than in trials on cutaneous melanoma. This study implies that combined checkpoint blockade represents the hitherto most effective treatment option available for metastatic UM available outside of clinical trials. Uveal melanoma (UM) is a malignant tumor of the eye that originates from the pigment cells of the choroid layer or the ciliary body which is clinically and biologically distinct from cutaneous melanoma. Although the incidence is much lower than that of cutaneous melanoma, UM belongs to the most common malignant intraocular tumors in adults . In apprPatients with metastatic UM have so far benefited little or not at all from the treatment innovations achieved in cutaneous melanoma in recent years. Neither targeted therapy with MEK inhibitors nor checkpoint blockade with ipilimumab or PD-1 inhibitors as monotherapy was able to significantly improve the prognosis of patients with UM , 5. The This study was designed as a retrospective multi-center explorative analysis. Patients were included if they had a diagnosis of stage IV UM and received combined checkpoint blockade of ipilimumab with a PD-1 inhibitor in any treatment line. A follow-up period of at least 3 months was required. The clinical data of 64 patients from 16 German skin cancer centers who met the inclusion criteria were investigated. The cases were collected from June 23, 2018 to October 4, 2019. Clinical data and the treatment outcomes of interest were extracted from the original patient records and merged into a central database prior to analysis. This study was approved by the institutional review board of the medical faculty of the Munich University Hospital  and was conducted in accordance with the principles of the Helsinki Declaration in its current version.The clinical data recorded at baseline prior to immunotherapy comprised demographics with Eastern Cooperative Oncology Group (ECOG) performance status, available information on the genotype, sites of metastasis, number of organ systems affected by metastases, and previous antineoplastic therapies. As potential serum biomarkers, lactate dehydrogenase (LDH), C-reactive protein (CRP), and the relative counts of lymphocytes (RLC), neutrophils (RNC), and eosinophils (REC) were specifically collected from patient charts and analyzed for their prognostic value , 14.Combined checkpoint blockade was carried out using different treatment schedules Table . IpilimuOverall survival (OS) and progression-free survival (PFS) were calculated as the time from the initiation of the first cycle of combined checkpoint blockade until melanoma-specific or treatment-related death and disease progression, respectively. Time-to-event analyses were calculated where death or progression were considered as events. If neither occurred or if patients were lost to follow-up, the date of the last documented presentation was used as a censored observation. The survival and progression probabilities were indicated with the Kaplan-Meier method for censored failure time data assuming proportional hazards. The survival curves were compared with the log-rank test . The durP-values were calculated based on Wald statistics [p-values were calculated and considered significant with values p < 0.05. All analyses were carried out with SPSS statistics version 23.0 (IBM) or GraphPad Prism version 5.01 (GraphPad Software).Cox proportional hazards regression modelling was applied to investigate the relationship of clinical risk factors and serum biomarkers with OS. Cox regression was performed as a univariate and multivariate analysis in a stepwise approach . Imputatatistics . The assA total of 64 (100%) patients with metastatic UM were included. Fifty patients (78.1%) were naïve to systemic treatment and received combined checkpoint blockade as first-line systemic therapy. Regarding genotype, the presence of monosomy 3 as risk factor was specifically investigated in 7 patients and identified in 2 of them. BRAF, NRAS and KIT were analyzed and reportedly wildtype as expected in 30, 22, and 20 patients, respectively. Mutations and inactivations of MBD4 which were previously linked to a hypermutator profile with high sensitivity to PD-1 inhibition were not investigated in any case , 19.n = 49, 76.6%). Serum LDH was elevated in 33 cases (51.6%) at baseline. Other baseline characteristics are listed in detail in Table Previous ipilimumab and PD-1 inhibitor monotherapy were applied in 2 (3.1%) and 12 (18.8%) cases, respectively. Both patients treated with ipilimumab before showed PD. Specifically, 4 patients (6.3%) had received nivolumab and 8 (12.5%) pembrolizumab before. In 4 cases, SD was achieved while 8 patients showed PD upon PD-1 inhibitor monotherapy. The median duration of the clinical benefit was 6.5 months in the 4 patients with SD. Liver-directed therapies were reported in 31 patients (48.4%). Most patients had an ECOG status of 0 (n = 10) relating to the entire population . Two patients achieved a complete response (3.1%) and 8 (12.5%) a partial response. The median duration of response was 25.5 months (range 9.0–65.0). Stable disease was achieved in further 14 cases (21.9%), resulting in a disease control rate of 37.5% with a median duration of the clinical benefit of 28.0 months (range 7.0–65.0) (Table The best ORR to combined checkpoint blockade was 15.6%  and 8 1.5% a parThe median time to response in patients with CR or PR after treatment initiation was 12 weeks (range 5–31). For the patients with SD, the median duration until the benefit was observed also amounted to 12 weeks (range 9–30). Interestingly, all 4 patients with SD after previous single PD-1 inhibitor blockade had PD to combined checkpoint blockade. Among the remaining 8 patients with PD after previous single PD-1 inhibitor blockade, one achieved a PR to combined checkpoint blockade. Thus, these data suggest that the effects of single and combined checkpoint blockade were observed independently from each other.A total of 78 AE were reported in 39 patients. Thus, the majority of patients developed any treatment-related AE (60.9%). Of all events, 37 AE were graded as severe (grade 3 + 4). They were observed in 25 patients . The treatment was discontinued in 25 cases (39.1%) due to unacceptable toxicity. However, no treatment-related deaths occurred during treatment or the observation period. The most common events were colitis (20.3%), hepatitis (20.3%), thyreoiditis (15.6%), hypophysitis (7.8%), fever (4.7%), and myalgia with myositis (4.7%). In all 5 cases with hypophysitis, the individual hormone axes including ACTH, cortisol, FSH, LH, TSH, and testosterone were investigated but not specifically graded. In 3 cases, the pituitary gland was enlarged in MRI examinations. All patients received systemic replacement of hydrocortisone. All AE are listed in Additional file p = 0.000096), the presence of bone metastasis (p = 0.011), and the best response to checkpoint blockade (p = 0.002) were significantly associated with OS  only . The median survival times were superior for the low plus intermediate group  compared to the high  and very high risk group   nor with the DCR (p = 0.446), suggesting that it was generally prognostic but not specifically predictive for the response to combined checkpoint blockade.We recently identified a prognostic score of the serum biomarkers LDH, CRP, and relative eosinophil count (REC) in a cohort of 94 UM patients receiving PD-1 inhibitors . The scoSubgroup analysis were performed for patients with metastasis to the central nervous system (CNS) at treatment initiation and for the treatment responders. Four patients showed an involvement of the CNS. Two of them had neurological symptoms. Two patients achieved SD, 2 showed PD. The median PFS for the CNS subgroup was 3.0 months (95% CI 0.0–6.1) while the median OS was not reached. In contrast, none of the treatment responders (CR or PR) had CNS involvement when the treatment was initiated Table . The medHere, we present a comparatively large cohort of patients with metastatic UM who were treated with combined checkpoint blockade. We detected a 15.6% ORR, with a 3.1% complete and 12.5% partial response rate. This response rate is in line with our previous report showing 16% ORR, although only 12 patients were evaluable for their radiologic response and the follow-up time was short . Other pAmong clinical parameters and serum biomarkers, only the ECOG performance status was a consistent prognostic factor in multivariate analysis. Other parameters such as serum LDH, CRP, and the REC showed a significant association neither with OS nor with the treatment response when they were considered as single factors. However, when integrated into a prognostic score, they were useful for risk stratification and discriminated groups with distinct survival probabilities. Thus, the risk score identified previously in a distinct cohort was successfully validated in this population . As therThe major limitations of this study are its retrospective design and the lack of a control group. When compared to historical controls, the median OS of 16.1 months is superior to survival estimates from other studies. Recently, the median OS benchmark for metastatic UM was identified as 10.2 months in a meta-analysis on individual data from 912 patients pooled from 29 trials . AnotherAltogether, our study implies that combined checkpoint blockade represents the hitherto most effective treatment option available for metastatic UM available in routine care outside of clinical trials. Based on our analysis and preliminary data from others, we hypothesize that the ORR achieved with combined checkpoint blockade will be 15–17%. Future trials are warranted to identify specific biomarkers for treatment response.Additional file 1. Adverse events of combined checkpoint blockade according to frequency.Additional file 2. Univariate Cox regression analysis of clinical and laboratory parameters.


H. pylori approaches 50%, with prevalence rates between 20 and 40% in developed countries and up to 90% in Africa and other developing nations of the world. Development of H. pylori-associated diseases is determined by a number of virulence factors. This study aimed at determining the prevalence of H. pylori infections and virulence genes ; the relationship between virulence factors and gastroduodenal diseases among patients.The global prevalence of Gastric biopsies were obtained from patients and cultured, DNA was extracted from cultured isolates and biopsies for PCR assay after which samples were investigated using standard laboratory procedures. Data of associated risk factors were obtained with the aid of questionnaires.H. pylori was detected in 115 (25.9%) from culture analysis and 217 (48.9%) by direct PCR method. Ninety-eight (85.2%) of the culture-positive patients were also detected by PCR giving an overall prevalence of 52.7% (234/444). The highest number of H. pylori isolates 76.9% (180/234) was obtained from patients suffering from pangastritis. The CagA virulence gene was found in 62% (145/234), dupA in 53.4% (125/234) and vacA in 90.6% (212/234). VacA genotype s1 m1 was the most prevalent [56.4% (132)] followed by s2 m2 [11.5% (27)], s2 m1 [10.3% (24)] and [s1 m2 9.4% (22)]. There was a significant association observed in vacA s1 and peptic ulcer disease, as well as vacA s1/m2 and gastric erosion (P < 0.05).Of the 444 participants, H. pylori detection and the associated risk factors investigated in the study were not significantly related.The study revealed a significant association between virulence genes and the development of certain forms of gastric infections while the variations in The online version of this article (10.1186/s12876-019-0986-0) contains supplementary material, which is available to authorized users. H. pylori approaches 50% , with prevalence rates between 20 and 40% in developed countries and up to 90% in Africa and other developing nations of the world  was obtained in pan gastritis patients, followed by participants with peptic ulcer 31 (13.2%). No H. pylori isolate was obtained in participants with gastric cancer. Virulence genes were determined for all confirmed H. pylori positive patients obtained from culture isolates and biopsy DNA out of which the cagA gene was detected in 62% (145/234), dupA in 53.4% (125/234), vacAs1 in 66.2% (155/234), vacAs2 in 20.1% (47/234), vacAm1 in 69.2% (162/234) and vacAm2 in 21.4% (50/234) strains.The endoscopy grading in 444 participants showed normal mucosa in 17 (3.8%) individuals, pan gastritis in 338 (76.1%), peptic ulcers in 55 (12.4%), gastric erosion in 23 (5.2%), gastric cancer in 3 (0.7%) and haemorrhages and polyps in 8 (1.8%). The highest number of cagA virulence gene was highest [111 (76.5%)] in pan gastritis patients followed by individuals with peptic ulcer [17 (11.7%)], while participants with haemorrhages and polyps had the lowest cagA detection [2 (1.4%)]. In this study, virulent allelic combination s1/m1 was predominant and found in 132 (56.4%) of the H. pylori strains, the s1/m2 was detected in 22 (9.4%) and the other genotypes, s2/m1 and s2/m2 were recorded in 24 (10.3%) and 27 (11.5%) strains respectively. Virulence genes cagA, dupA, vacA s1/m1 were detected in all disease conditions except gastric cancer where H. pylori was not found. Detection of vacA s1 was significantly high 26 (16.8%) in patients with peptic ulcer disease (P = 0.036). Similarly, vacA s1/m2 was considerably high in patients with gastric erosion (P = 0.0029) (Table H. pylori strains were positive for vacA genotypes (data not exclusive but form unions and intersections).The cagA, dupA and vacA genotypes in H. pylori strains. The vacA s1 was found to be significantly high (P = 0.000) in the cagA and dupA positives patients. Similarly, vacA m1 positive individuals recorded a significantly high cagA 123 (75.9%) and dupA 100 (61.7%) genotypes. Furthermore, there was a high detection rate of cagA 82.6% (109/132) and dupA 63.6% (84/132) in the vacA s1/m1 positive patients. The rest of the vacA genotypes were not significantly high in cagA and dupA positive individuals.Table H. pylori have been proposed. The choice usually depends on the availability of materials, sampling population, condition of patients, and competency or experience of the investigator. In this study, the two methods complement each other for diagnosis and analysis. The choice of culture technique was based on a high record of specificity and availability of isolates for antibiotic susceptibility test. Similarly, PCR assay was chosen due to its high sensitivity reported by many authors [H. pylori in agar medium as reported by some authors [Various diagnostic methods of detecting  authors . Compari authors . In thisThe overall prevalence of 52.7% obtained in the current study is relatively low compared to some other previous studies in developing nations where higher prevalence figures were recorded . HowevercagA and vacA have been related to inducing gastric adenocarcinoma, mucosal associated lymph tissue (MALT)-lymphoma, and peptic ulcer disease (PUD) in patients [dupA is associated with duodenal ulcer [H. pylori varies geographically [cagA with repeated EPIYA segment sequence A-B-D has a higher binding affinity than the western-type cagA with sequence A-B-C resulting in higher risk of peptic ulcer and gastric cancer [vacA m2, dupA negative and cagA negative H. pylori strains [The bacterium is known to possess a wide degree of genomic and allelic diversity . This sppatients  while dual ulcer . Studiesphically , 35. Thic cancer . Further strains .cagA, vacA and dupA genotypes of 234 H. pylori strains. The majority of strains were vacA 90.6% (212/234), followed by cagA 62% (145/234) and dupA 53.4% (125/234). Among the vacA genotype combinations, vacA s1/m1 was the highest at 56.4% (132/234).In this study, to establish a possible association between the presence of the major virulence factors and disease outcome among patients attending CHBAH, Soweto, we analyzed the status of CagA is one of the most studied virulence genes of H. pylori and this toxic protein has a molecular size of 120 to 145 kDa and is found on the cag-PAI. The strains that carry the PAI are known to be more virulent than those lacking it [cagA positive strains obtained in our study is similar to researches conducted in Tunisia and Morocco where 61.6 and 61.2% cagA were reported respectively [cagA previously reported elsewhere in South Africa. For example, in Eastern Cape, South Africa, 90% cagA positive strains were reported [cagA positive were found among asymptomatic children age between 6 and 15 years in another study. Globally, in Taiwan, 83% cagA positive strains were found in isolates from patients with chronic gastritis and peptic ulcer [cagA was detected [cagA was reported among Alaskans (USA) [cagA has been documented elsewhere such as Cuba [cking it . The preectively , 40. Howreported , while iic ulcer . Among Tdetected  and 85% ns (USA) . Also, 9ns (USA) . On the  as Cuba , Pakista as Cuba .vacA) has been implicated to play a major role in gastroduodenal disease progression. The gene is a pore-forming toxin secreted through an auto transporter. The mechanism of its toxigenic effect occurs by binding to the receptor of the eukaryotic cell lipid sphingomyelin. The gene targets the mitochondria where it induces apoptosis and formation of large intracellular vacuoles. VacA polymorphisms are divided into signal, intermediate, middle and deletion regions. Of all the allelic combinations, the vacA s1/m1 alleles are the most virulent, while the s1/m2, s2/m1 and s2/m2 genotypes demonstrate little to no pathogenicity. Our study showed vacA s1 to be predominant, which is similar to findings reported elsewhere such as Eastern Cape South Africa [vacAs1 subtypes and its link with disease status. On the other hand, a lower prevalence of s1 type allele has been reported in Jordan [Vacuolating cytotoxin  predominantly of the subtypes s1 and m1 which makes patients likely to be more prone to H. pylori-associated diseases. The absence of vacA in 22 strains in the study could be a result of the genetic structure of the strains or exposure to adverse stomach conditions [vacA m1 (69.2%) were more than vacA m2 (21.4%). The outcome is in line with findings of other authors who reported a higher prevalence of vacA m1 than m2 [vacA polymorphs differ from strains due to genetic composition and geographical location of the organism. For example, m1 genotype appears more than m2 in African population while the two subtypes are almost equally distributed within Europe and Latin America [Generally, our finding shows a high prevalence of nditions . In the  than m2 –52. Howe than m2 , 43. Num America .cagA and vacA virulence genes among H. pylori strains [vacAs1 and peptic ulcer as well as vacAs1/m2 and gastric erosion. The reason probably could be the influence of host genetic make-up and environmental conditions [vacA s1/m1 genotype may be considered an important virulence factor in the development of gastric diseases [This result compared to a study conducted in Nigeria is lower in terms of the presence of  strains . Howevernditions . In the diseases .dupA) has been considered as a marker for the peptic ulcers by some authors [dupA as a predictor of duodenal ulceration in Belgium, South Africa, China and North America [dupA positive isolates in our study, while the lower prevalence of dupA (18.8%) was reported in Northern Iraq [Duodenal ulcer promoting gene  occurred, but none was accompanied with H. pylori infection. Due to limited data of patients with gastric cancer, though not uncommon in Africa, we cannot extrapolate gastric cancer and H. pylori negativity. Some studies have described factors such as viral infection, habit, immunological disorders and gene mutations as the aetiology of gastric cancer [c cancer . This stvacAs1 and the development of peptic ulcer disease as well as vacAs1/m2 and gastric erosion. In South Africa and other developing nations, the occurrence of H. pylori virulence factors is common, but their involvement as disease markers is not really pronounced. Studies of H. pylori virulence factors in South Africa could be important for a clinical and epidemiological survey to better understand the disease pathology.The current study showed a vital correlation between Additional file 1:Patient questionnaire. Contains patients investigation form, gastroenterology result sheet and consent form. (PDF 420 kb)Additional file 2:Ethics certificate. Contains ethics certificates from the CHBAH and University of Fort Hare. (PDF 154 kb)


Background: Acute kidney injury (AKI) is an important complication of idiopathic nephrotic syndrome (INS) and is associated with adverse outcomes, especially the development of chronic kidney disease (CKD). We aimed to determine the clinical profile of children with INS who developed AKI and its short-term outcome.Material and methods: This prospective study was conducted from March 2014 to October 2015. A total of 119 children of INS (age: 2–18 years) fulfilling the pediatric RIFLE criteria for the diagnosis of AKI were enrolled and followed up for 3 months to determine the outcome. Factors predisposing to CKD were studied.Results: The mean age at presentation was 8.8 ± 3.59 years and males were 74 (62.2%). At presentation, 61 (51.3%) children were in Risk category, 43 (36.1%) in Injury category, and 15 (12.6%) in Failure category. Most of them (41.2%) had steroid-resistant nephrotic syndrome (SRNS) and focal segmental glomerulosclerosis (FSGS) on histopathology (33.6%).Infections were the major predisposing factor for AKI in 67 (56.3%) cases. Drug toxicity was the next common, found in 52 (43.7%) children. A total of 65 (54.6%) children recovered from AKI, while 54 (45.4%) did not. CKD developed in 49 (41.2%) non-recovered cases and 5 (4.2%) children succumbed to acute illness. SRNS, cyclosporine use, FSGS on histology, and drug toxicity were significant factors associated with the development of CKD.Conclusion: AKI associated with INS is a reversible condition in most cases but it can progress to CKD, especially among those who have SRNS, FSGS, and drug toxicity. INS was defined as the presence of edema, serum albumin <25 g/L, proteinuria >40 mg/m2/hour, or urine protein creatinine ratio >200 mg/mmol. The method of laboratory determination of serum creatinine (S.Cr) was done by the Jaffe method. eGFR was calculated by the Schwartz equation (K × height/S.Cr).2.This prospective observational study was conducted at the Pediatric Nephrology Department of Sindh Institute of Urology and Transplantation (SIUT) from March 2014 to October 2015. The study was conducted in accordance with tenets of Declaration of Helsinki. All children with INS between 2 and 18 years of age fulfilling the modified pediatric RIFLE criteria were enrolled for the study and followed up for three months. All children with secondary NS, acute-on-chronic renal failure, age less than 2 years at the time of diagnosis of INS and base line estimated glomerular filtration rate (eGFR) less than 90 ml/min/1.73 m2).2 by the Schwartz equation. CKD was defined as persistent deterioration in renal functions for more than 3 months. Infection, sepsis, and severe sepsis were defined according to surviving sepsis campaign guidelines.AKI patients were diagnosed using the modified pediatric RIFLE score through the use of eGFR criteria only . After patients improved clinically, they were followed up in the outpatient clinic and S.Cr was done according to clinical condition of the patients.t-test, Chi-square test, or Fisher exact test. All statistical tests were two-tailed. p Value ≤0.05 was considered statistically significant.All data were analyzed by using SPSS version 16 . Normal or near normally distributed variables were reported as means ± standard deviation (SD). Frequency and percentage were calculated for qualitative variables. Categorical data were tested using the Student Overall, 119 children, with INS were studied for AKI during the study period. The mean age of the entire cohort was 8.8 ± 3.59 years (range: 2.2–16 years). There were 74 (62.2%) males and 45 (37.8%) females. Baseline clinical and biochemical characteristics of children with AKI in INS are depicted in n = 67, 56.3%). Types of infections included: spontaneous bacterial peritonitis (SBP) in 24 (20.2%), acute gastroenteritis (AGE) in 16 (13.4%), sepsis in 14 (11.8%), pneumonia in 10 (8.4%), malaria in 2 (1.7%), and brain abscess in 1 (0.8%). Drug toxicity was the second most common cause, found in 52 (43.7%) cases. It included cyclosporine in 38 (31.9%), tacrolimus in 11 (9.2%), and ACE inhibitors in 3 (2.5%) cases.The most probable etiologic factors predisposing to AKI development in nephrotic children are shown in An analysis of the short-term outcome of AKI in INS showed that slightly more than half of children (65: 54.6%) recovered from AKI. Of the remaining 54 (45.4%) who did not, 49 (41.2%) developed various degrees of CKD and 5 (4.2%) patients died. A total of 17 (14.3%) patients progressed to CKD stage 2, 18 (15.1%) to CKD stage 3, 10 (8.4%) to CKD stage 4 and 4 (3.4%) to CKD stage 5/ESRD. The cause of death was septic shock in 5 (4.2%) patients. Out of these 5 patients, 2 were in the Risk category and 3 had developed Failure according to modified pediatric RIFLE criteria at the time of presentation.The factors responsible for the progression of AKI to CKD in children with INS are shown in n = 61, 51.3%), as reported previously by Renault et al.To the best our knowledge, this is the largest single center and first prospective study to date examining the incidence of AKI in children with INS and their short-term outcome in a developing country from South Asia. We used pRIFLE classification to diagnose AKI,n = 74, 62.2%) and most children belonged to 5–10 years age group . These results are comparative to a number of previous studies on this subject.,,,,In this study, males were predominant (This study has several strengths. This is one of the largest studies in the pediatric population on this subject from a developing country using pRIFLE criteria for the diagnosis and categorization of AKI. The prospective nature of the study and follow-up of patients, albeit for short period, for determining outcome are also added attributes in a resource-constrained setting.There are certain limitations in the study too which must be kept in mind when interpreting the results from this study. These include the origin of study from a single center, lack of biopsies in all patients, and a short follow-up period. We also did not analyze the trend of GFR in the cohort to demonstrate progression or stability of GFR in these children due to short follow-up period. In spite of these limitations, we believe that our study is one of the largest studies on the incidence of AKI in children with INS from any single center in a developing country. This will help increase awareness of the nephrologists about this complication, which can lead to CKD in many children. The increased awareness coupled with attention to hygiene and avoidance of potentially nephrotoxic medications may possibly be helpful in declining progression of AKI to CKD.AKI associated with INS in most cases is a reversible condition but it can progress to CKD, especially in those with SRNS, FSGS and drug toxicity. Further, large-scale, multi-center studies with long-term follow-up is needed to identify risk factors and prognosis of AKI in INS.


During skull ontogenesis, growth centers in the skull base and calvarial bones allow gradual expansion of the cranial vault. Premature growth termination of cranial base synchondroses and/or calvarial sutures can result in devastating skull dysmorphologies. There is evidence to believe that a premature closure in one or more cranial growth centers contribute to the brachycephalic skull morphology in dogs. To provide a proof of concept for the non-invasive investigation of ontogenetic changes in cranial sutures and synchondroses in living dogs, we compared magnet resonance imaging (MRI) and computed tomography (CT) with histologic findings. Our aim was to determine the in vitro sensitivity and specificity for conventional clinical imaging methods in the assessment of cranial suture closure and synchondroses ossification in dogs.The evaluation of cranial base synchondroses in MRI had a sensitivity of up to 93.1% and a specificity of 72.7% dependent on the observer. The evaluation of cranial base synchondroses in CT had a sensitivity of 92.2% and a specificity of 86.4%. Suture assessment on MRI suture assessment had a sensitivity of 82.1% dependent on the observer and a specificity of 19.3%. CT suture assessment had a sensitivity of 85.1% and a specificity of 40.4% in dependence of the observer.Conventional cross-sectional imaging techniques (MRI and CT) allow reliable assessment of the open or closed state of synchondroses within the cranial base. In contrast CT and MRI are not suitable for a reliable assessment of the cranial sutures in dogs. The mammalian skull develops as a composite structure that consists of a multitude of tissues originating from different embryonic precursors . The dynContrary to the calvaria, the bones of the cranium base develop by enchondral ossification , 6, 7. TThe growth of individual bones is regulated within these centers by complex signal cascades, involving multiple receptors and transcription factors within both kinds of growth centers . Any dis. However, the value of these imaging methods for the assessment of synchondrosal and sutural status has never been determined.Cross sectional diagnostic imaging methods (MRI and CT) would allow the examination of large cohorts of dogs of different breeds in vivoThe aim of the present study was, therefore, to compare imaging findings with histological preparations in order to determine the sensitivity and specificity for conventional clinical CT and MRI in the assessment of the open or closed status of cranial synchondroses and sutures in dogs.Due to the fragility of the structures, especially in very young puppies, twenty-two sutures and five synchondroses were lost during sample preparation. 433 sutures and 112 synchondroses could be histologically evaluated.In all immature dogs, a double-sided arrangement of chondrocytes in a hyaline homogenous cartilage matrix was observed between the bone tissue of the basicranial bones. The cartilage consisted of chondrocytes being distributed into a central resting zone, as well as bilateral proliferating, and hypertrophic zones Fig.  A, B 1919. In th90 synchondroses (80.4%) were evaluated as closed, and 22 (19.6%) were assessed as open. The spheno-occipital synchondroses were classified as open in 31 (83.78%) specimen as closed in 6 (16.22%). Of the 38 examined inter-sphenoidal synchondroses, 32 (84.21%) were classified as open, and 6 (15.79%) as closed. Of 37 examined spheno-ethmoidal synchondroses, 27 (72.97%) were classified as open and 10 (27.03%) as closed.Suture morphology ranged from straight-edged plane sutures  of the sutures were categorized as open type A syndesmoses, 78 (18%) were classified as type B syndesmoses (open). No suture line was observed in 115 (26%) of the examined sutures.In dependence of the observer, 87  - 89  synchondroses were classified as open, and 22 as closed. For all synchondroses there was a high accordance of MRI and histological findings. A sensitivity of 93.3% (confidence level 95% of 77.9–99.9%) and specificity of 83.3–100% (confidence level 95% of 35.9–100%) was found for the spheno-occipital synchondrosis. A high sensitivity of 93.5% (CI 95% of 78.6–99.2%) and low to moderate specificity of 50 (MS) - 66.7% (DF) (CI 95% of 11.8–95.7%) for intersphenoidal synchondrosis. A high sensitivity of 84.6 (DF) - 92.3% (MS) (CI 95% of 65.1–95.6%) and a moderate specificity of 70% (CI 95% of 34.8–93.3%) was shown for spheno-ethmoidal synchondrosis -85 (MS) synchondroses were determined as open. In 91.1–93.3% of the cases (CI 95% of 84.2–95.6%) synchondroses were identified correctly as open. Closed synchondroses were correctly identified in 86.4% of the samples . The spheno-ocipital synchondrosis showed the highest sensitivity of 96.8% (CI 95% of 83.3–99.9%) and highest specificity of 100% (CI 95% of 60.7–100%) The intersphenoidal synchondrosis showed a high sensitivity of 93.7% (CI 95% of 79.2–99.2%) and specificity of 83.3% (CI 95% of 35.9–99.6%). The lowest accordance of CT and histological findings was shown with a high sensitivity of 85.2% (CI 95% 66.3–95.8%) and a high specificity of 80% (CI 95% of 44.4–97.5%) in the spheno-ethmoidal synchondrosis (Table MRI suture assessment shows a moderate to high sensitivity of 72.2 (DF) -82.1% (MS) (CI 95% of 66.0–86.7%) but a low specificity of 14.4 (DF) -19.3% (MS) (CI 95% of 9.7–25.6%). Sensitivity and specificity for each individual suture and synchondrosis is shown in Table CT suture assessment shows a high sensitivity of 81.7 (DF) -85.1% (MS) (CI 95% of 76.2–89.3%) but a low specificity of 37.8 (DF) -40.4%(MS) (CI 95% of 48.5–75.8%). Individual suture and synchondrosal assessment is summarized in Table In dependence of observer, CT could not assess sutural state in 26 (MS)-31 (DF) of 455 sutures (6.8–8.1%).Regarding to the synchondroses of the cranial base an almost perfect agreement between the observers was shown for inter-sphenoidal synchondrosis (ϗ = 0.894) and a substantial agreement for the spheno-occipital (ϗ = 0.771) and spheno-ethmoidal synchondrosis (ϗ = 0.745). Depending on the examined sutures observer accordance in MRI reaches from 70.3% (CI 95% of 53–84.1%) to 94.9% (CI 95% of 82.7–99.4%). Spheno-frontal , squamosal , lambdoid (ϗ = 1), sagittal (ϗ = 1) and palatinal suture (ϗ = 0.869) showed an almost perfect agreement between the observers. Interfrontal (ϗ = 0.784), coronal (ϗ = 0.649) and sagittal suture (ϗ = 0.714) showed a substantial agreement  from cartilage to bone tissue account for this result. However, not all sutures could be assessed equally well. The spheno-ethmoidal synchondrosis has a lower sensitivity compared to spheno-occipital and intersphenoidal synchondrosis in both CT and MRI. The microanatomy of this synchondrosis differs from the others and is more difficult to define within the cranial base as it is not always straight but crescent-shaped . The traAssessment of suture status was more difficult in both modalities. Although CT correctly identified a cranial suture as open (high sensitivity), it was less reliable in identifying a truly closed suture (low specificity). MRI revealed a moderate sensitivity and a low specificity for the assessment of sutural state. The low specificity for both modalities can be attributed to the small size of the examined structures, which can be hardly visible even on a prepared skull, especially in small dogs. Although CT and MRI scanning had a submillimeter resolution in this study, the small size of some sutures in very young and older dogs (micrometer range) complicates clear identification. Cranial sutures can be reliably studied using micro-CT of human skull specimens . HoweverThe microstructure of the suture might also have an influence on its assessment. The spheno-frontal sutures and squamosal sutures were particularly difficult to examine. These two are overlapping sutures (sutura squamosa), with extremely thin sutural gaps, which are located laterally on the skull curvature, making an assessment even more difficult. Butt sutures  do not overlap and have a wider sutural gap, which makes them easier to identify. Furthermore, the localization of the sagittal, and lambdoid sutures is marked by the external sagittal crest or the nuchal crest, respectively, which simplifies their identification in both imaging and histology.Beyond size and morphology, the variability between the observers indicates that assessment of sutures is also experience dependent. Classifying the maturation stage of cranial sutures in children requires significant training and proficiency . AlthougIn humans, the end point of cranial vault growth is determined upon fusion of the sutures in the third decade of life , but theOur study presents one important limitation. Histological sections without visible sutures were rated as fused. This finding might be based on the presence of a truly ossified suture, or because the suture was left out during sample cutting. Relatively simple at birth, the microarchitecture of many sutures gain complexity during growth. We observed a three-dimensional structure and their internal course must not necessarily correspond to the visible suture on the surface. The validity of our results might have increased further if the whole excised bone/suture sample would have been fully sliced, but we refrained from the examination of the whole suture course as this process is extremely time consuming.Conventional imaging techniques are very useful to assess the open or closed status of synchondroses within the cranial base. Sutural closure is difficult to diagnose in MRI and CT. Assessment is dependent on observer experience. Histologic examination remains the gold standard for suture assessment.The aim of the present study was, therefore, to compare imaging findings with histological preparations in order to determine the sensitivity and specificity for conventional clinical CT and MRI in the assessment of the open or closed status of cranial synchondroses and sutures in dogs.The heads of 40 dogs of different breeds , were collected from the Department of Veterinary Clinical Sciences, Clinic for Small Animals and from the Clinic for Gynecology, Andrology and Obstetrics of the Justus-Liebig-University, Giessen . Dorsal, sagittal, and transvers T2-weighted (W) images with a 2 mm slice thickness and a 0.2 mm slice interval were acquired  120 ms, repetition time (TR): 2900 ms. T1-FFE weighted dorsal and transversal images with a slice thickness of 1 mm were obtained (TR 25 ms TE 6.9 ms). Field of view was 120 × 120 mm in small dogs and 210 × 210 mm in large dogs. Matrix was 288 × 288 in small dogs and 384 × 384 in large dogs leading to a pixel size between 0.625 × 0.625 mm and 0.54 × 0.54 mm.Post mortem MRI of the head was obtained using a high field scanner . Transvers images with a slice thickness of 0.8 mm were obtained using 120 kV, 321 mA and a field of view of 133 mm. Data were processed using a bone algorithm (window width 2500 and window level 500).Post mortem CT examination was performed using a sixteen slice CT scanner All images were retrieved from the relevant picture archiving system and evaluated by a board certified neurologist (MJS) and a doctoral student (DF). The experiments were performed using anonymized and randomized image data sets. The observers were blinded to age and breed of the dog. Studies were evaluated with open source DICOM viewing software and window levels, window widths, and magnification were adjusted as needed in order to optimize visualization of bone. The following cranial growth centers were examined: Interfrontal (metopic) suture Fig. d: S5/7, In CT, an open synchondrosis or suture was defined as a hypodense zone between well-defined hyperdense borders of the calvaria or cranial base bones Fig. . A closeIn MRI, an open suture was defined as a hypointense signal interruption of the hyperintense calvarial bone marrow signal in T2 weighted images. An open synchondrosis was defined based on the presence of a broad hyperintense signal zone (cartilage) with well defined, hypointense borders (endplates) Fig. . A close). Suture morphology was assessed as precisely as possible in a plane of sectioning perpendicular to the individual suture orientation [). Three serial sections of 5 μm were stained using Masson-Goldner protocol in order to visualize bone, cartilage and fibrous connective tissue. The stain produces blue or green collagen and deep red mineralized bone.After postmortem scanning soft tissues were carefully removed from the skull and the whole head was immersion fixed in 10% neutral buffered formalin. A standardized procedure was devised to cut out the sutures and synchondroses from each head using a diamond coated sawblade ) and fibroblasts (> 20 in 3 FOV)) . Non-existence of cartilage or fibrous tissue was evaluated as a closed synchondrosis/suture. Furthermore, it was determined whether fibrous- or cartilage tissue was present throughout the suture/ synchondrosis, or whether bony bridges were present. These data was used to assign each synchondrosis/suture to one of the following categories: 1) open synchondrosis/ suture; 2) partly closed synchondrosis /suture; 3) closed synchondrosis/suture , moderate (65–79%) or low (< 64%). Interobserver variability was obtained using the kappa coefficient. A kappa value < 0.2 implies slight agreement, 0.21–0.4 fair agreement, 0.41–0.6 moderate agreement, 0.61–0.8 substantial agreement and > 0.81 almost perfect agreement.


To evaluate the efficacy and safety of transscleral cyclophotocoagulation (TS-CPC) limited to 180° of ciliary body ablation in patients with various forms of refractory glaucoma.Thirty eyes with refractory glaucoma treated with 180° TS-CPC were retrospectively analyzed for intraocular pressure (IOP) reduction and success rates. Patients’ age, gender, type of glaucoma, number of diode laser treatment sessions, postoperative complications, number of hypotensive medications required to control IOP, and best corrected visual acuity (BCVA) were evaluated. The criteria for success were defined as postoperative IOP <21 mmHg or >20% decrease in IOP with or without additional medical treatment.The mean age of all patients was 51.3±26.9 years . The mean postoperative IOP level (23.9±8.5 mmHg) was significantly lower than preoperative IOP (39.2±8.9 mmHg) (p<0.001). The success rate was 66.6% after the first laser treatment and reached 86.7% following repeat laser treatments over an average follow-up period of 22.2±19.9 months. The need for topical hypotensive medications decreased from 2.8±1.0 preoperatively to 2.4±1.3 following TS-CPC (p=0.048). Two patients (6.6%) had a one-line decrease in their BCVA following TS-CPC. Transient hypotony and hyphema developed in 4 patients (13.3%). Total laser energy delivered did not correlate with either preoperative  or postoperative IOP .TS-CPC limited to 180° of ciliary body ablation is associated with a reasonable success rate and low incidence of adverse effects in patients with refractory glaucoma. During this process, the surrounding tissues including the ciliary body and its vascular supply are destroyed by the resultant thermal energy transfer.5Destruction of the ciliary body using various methods is an option for the management of refractory glaucoma when conventional medical and or surgical modalities fail to adequately control intraocular pressure (IOP).6 Reported IOP reduction for this procedure has varied between 12% and 66% in different studies.8 The extent of response to TS-CPC differs depending on the underlying glaucoma, with higher success rates attained in primary open-angle glaucoma (POAG), neovascular glaucoma (NVG), and inflammatory glaucomas compared with congenital, juvenile, and traumatic glaucoma, and glaucoma following cataract surgery .9TS-CPC has been established as an alternative therapeutic modality to tube shunt or augmented trabeculectomy for refractory glaucoma, especially in eyes with poor visual potential.6 It has been shown that more extensive treatment of the ciliary body and total energy delivery of >80 J are associated with unfavorable outcomes such as hypotony and phthisis.3 Analysis of data from standardized treatment protocols may help refine the TS-CPC technique with potentially improved outcomes and reduced adverse effects. Thus, the purpose of the current study was to evaluate the efficacy and safety of TS-CPC limited to 180° of ciliary body ablation in patients with various forms of refractory glaucoma.Despite the widespread use of TS-CPC, published reports reveal that treatment centers vary significantly with respect to their laser energy delivery and postoperative management schemes. Extent of ciliary body treatment, total amount of delivered energy, and use of postoperative anti-inflammatory medications are likely to impact overall efficacy and safety outcomes.This was a retrospective study undertaken at a single academic institution. The study adhered to the tenets of the Declaration of Helsinki and was undertaken with institutional review board approval from the Institutional Ethics Committee for Human Research.The clinical records of patients who were diagnosed with glaucoma and underwent TS-CPC between 2006 and 2015 were reviewed. Parameters for the study included type of glaucoma, number and type of anti-glaucoma medications, visual acuity, slit-lamp biomicroscopic examination findings, and IOP measurements. Goldman applanation tonometry (GAT) and Perkins tonometry were used to obtain IOP measurements in adults and children, respectively. Data related to pre- and post-treatment IOP levels, complications, and the need for topical glaucoma medications were extracted for all patients. Treatment details included number of sessions and number of diode laser spots applied per session.The entire treatment protocol was performed under operating room conditions. The procedures were performed under either general anesthesia or retrobulbar anesthesia . TS-CPC was performed using a transscleral contact fiberoptic G probe attached to the OcuLight SLx semiconductors laser unit . Laser duration was set at 1,500 ms in all patients. The probe was placed approximately 1.5 mm posterior to the limbus. For each session, an area of 180° around the limbus was treated. The laser power was initially set at 1,500 mW and was increased by 150 mW until the “pop” sound was heard, at which time power was decreased until no audible pops were heard, up to a maximum level of 3,000 mW. Transillumination was used to identify the ciliary body position if uncertain, as in congenital glaucoma or in those with a previous history of intraocular surgery. The laser spots were not applied at the 3 and 9 o’clock positions to avoid potential damage to the ciliary vessels and nerve. Following the procedure, topical anti-inflammatory therapy was initiated. Hypotony was defined as an IOP level of ≤5 mmHg. Patients were followed up at 1 day, 1 week, and 1 month after the procedure and every 3 months thereafter. Patients were not included if they were not followed for at least 3 months. The total cyclodiode energy (J) was calculated by multiplying the number of laser burns by the duration (s) of each burn by the power (W) of each burn. If more than one session was applied, cumulative energy amounts from all sessions were calculated.The criteria for success included IOP <21 mmHg with or without additional treatment, or a >20% decrease in IOP. Patients who were found to have inadequate IOP control at the 1-month postoperative visit or beyond received additional medical or surgical treatments.Microsoft Excel software  were used for data collection. Descriptive data were presented as mean ± SD. Data analysis was performed using SPSS 22.0  software package. Independent samples t-test was used for comparisons or Wilcoxon signed rank test was used where necessary. The Spearman’s Rho test was used in correlation analyses. A p value of <0.05 was accepted as statistically significant.Thirty eyes of 30 patients  were included in this study. The mean age of all patients was 51.3±26.9 years (range=1-84 years). Types of glaucoma included in the study are summarized in The mean postoperative follow-up period was 22.2±19.9 months (range=3-84 months) after the first cyclodiode laser application. There was a significant (30.9%) IOP reduction at the 3-month post-treatment visit (27.1±8.1 mmHg) compared to baseline (39.2±8.9 mmHg) (p<0.001). Successful results were obtained in 20 patients (66.6%) at the 1-month post-laser control. Postoperatively, 80% of patients who underwent laser treatment still required anti-glaucoma eye drops for IOP control. Sustained IOP control for a duration of at least 12 months was achieved in 14 patients (46.6%).A second TS-CPC session was required in 16 patients (53.3%) whose IOP could not be adequately controlled following a mean interval of 5.4±3.0 months from the initial TS-CPC procedure. In this subset of patients, postoperative success was attained in 50% of cases. Following the second treatment session, an overall successful outcome was achieved in 73.3% of study eyes. Four (13.3%) patients needed a third laser session within 12 months. Repeat treatments were performed in eyes which had congenital, juvenile, and neovascular glaucoma . During At final evaluation, the mean postoperative IOP level (23.9±8.5 mmHg) was significantly lower than the mean preoperative IOP (39.2±8.9 mmHg) (p<0.001). In patients with successful outcomes, the mean percentage of IOP reduction was 43.8±17.3%, 46.7±17.4%, and 43.9±6.3% respectively after the first, second, and third cyclodiode laser treatment sessions. The number of active medications decreased from 2.8±1.0 to 2.4±1.3 following treatment (p=0.048). Mean IOP levels, number of glaucoma medications, and mean amount of total energy are presented in The mean age of the patients who required repeated (≥2) diode laser applications (44.2±30.9 years) was not significantly different than those who received a single laser application (59.5±19.4 years) (p=0.112).The mean number of treatment sessions was 1.6±0.7. The mean laser energy delivered per treatment session was 35.4±16.6 J. The cumulative laser energy delivered after all treatment sessions was 58.9±34.7 J per patient. There was no correlation between the amount of laser energy delivered per session and preoperative IOP level , postoperative IOP level , or patient age . The number of sessions was positively correlated with total delivered energy  and negatively correlated with postoperative number of glaucoma medications . Total amount of energy delivered did not correlate with preoperative IOP , postoperative IOP , number of preoperative  or postoperative  glaucoma medications, nor with mean IOP reduction  following diode laser treatment.Cyclodiode photocoagulation is frequently employed at a clinical stage where adequate IOP control is not achieved despite repeated surgical interventions and maximum medical therapy in glaucoma patients with severely compromised visual function. Despite its proven efficacy, the utility of this treatment modality in achieving IOP control has often been eclipsed by unpredictable responses as well as its potential adverse effects of persistent hypotony and the dreaded complication of phthisis bulbi. The findings of the current study reveal that limiting the extent of laser treatment to 180 degrees is associated with a low incidence of adverse effects and appears to be relatively safe, with about 67% of eyes achieving satisfactory IOP lowering after a single treatment session.10 Another study by Mistlberger et al.1 found the success rate of this procedure with a single treatment was 66.7% at 1 year and 49.7% after 2 years. Although long-term follow-up data for patients treated with a single session were not available, we observed that the 1-month success rate of 66.6% fell to 46.6% at the end of the first year. Thus, the findings of the current study as well as those from other studies indicate a time-dependent loss of IOP control following TS-CPC.In a previous study using 270° ciliary body ablation on 27 eyes, the cumulative probability of success of TS-CPC was 72% in the first and 52% in the second postoperative year based on success criteria similar to those used in the current study.2 Overall, data available from previous studies support the beneficial effect of repeat treatment sessions for IOP control in patients undergoing TS-CPC. Our study findings show that even 180-degree repeat laser treatment is able to provide additional benefit in refractory glaucoma cases.In our study, the cumulative percentage of eyes successfully treated with a single treatment session was found to be 46.6% at the end of 1 year, with repeat laser sessions resulting in a higher success rate (86.7%) at the end of an average of 22.2 months of follow-up. Similar results were obtained in another study that had a 58.9% success rate after the first laser session and a significant increase to 81.3% success with a second treatment session.2 in which TS-CPC was applied over 270° of the ciliary body, the IOP reduction rate was found to be 52.6% in the first 7 months of follow-up. In a similar study, Singh et al.11 found the reduction in IOP to be 58.5% at 9 months post-treatment. In the current study, the IOP reduction rate was 30.9% and 39.0% at 3 and 22.2 months, respectively. One plausible explanation for the limited IOP reduction observed may be related to the lesser extent of ciliary ablation (180° versus 270°) performed in the current study.In a study by Murphy et al.12 showed an increased need for multiple laser treatment in young patients, which the authors believed was potentially attributable to a higher level of baseline aqueous humor production and more vigorous healing response in the younger population.A second laser session was required in 53.3% of patients in our study. This group consisted predominantly of cases of juvenile glaucoma, congenital glaucoma, and neovascular glaucoma. Although we did not observe a greater need for repeat interventions among younger patients, a previous study by Threlkeld and Johnson12 demonstrated a significant IOP reduction following TS-CPC in patients with neovascular glaucoma and emphasized caution for post-operative hypotony. In our study, two patients who developed hypotony had either neovascular or juvenile glaucoma. In both patients, preoperative IOP values and mean total energy delivered were higher than the total group average . Despite an overall adequate IOP reduction in these patients, complications including hypotony and hyphema occurred in 2 cases (6.6%). Thus, it is recommended that hypotony may occur infrequently even with 180 degrees of ciliary body ablation and that vigilant IOP monitoring should be practiced even in patients who undergo limited  laser ablation.Oguri et al.9 suggested that the success rate of TS-CPC may be related to the type of glaucoma. The authors reported a high success rate in patients with POAG (89.5%), NVG (86.8%), and inflammatory glaucoma (75%) and a lower success rate in traumatic (57.1%), aphakic (57.1%), and congenital or juvenile (62.5%) glaucoma.9 In our study, patients with NVG achieved a success rate of 55% with one and 100% with repeat laser treatment. All cases with POAG (n=3) achieved long-lasting IOP control with a single treatment session. On the other hand, the success rate was unsatisfactory for patients with congenital and juvenile open-angle glaucoma, who required repeat laser sessions and ultimately were unable to achieve adequate IOP control , this number decreased to 2.4±1.3 (p=0.042). Four patients (13%) could be taken completely off topical hypotensive medications following TS-CPC. Thus, the findings of our study are in agreement with those of previous reports showing a reduced need for glaucoma drops following laser treatment, but the need to continue medical treatment in the majority of patients postoperatively.16 while others fail to detect this association.11 In our study, no association was found between energy delivered and postoperative IOP. This discrepancy may stem from the fact that there is really no anatomic landmark during TS-CPC to ensure exact placement of the probe tip over the ciliary body and no method available to assess the energy delivered to the ciliary body tissue.As there is no standardization of the magnitude and extent of laser energy used during TS-CPC, it is difficult to make comparisons between different studies. Certain studies reveal a correlation between total amount of energy and success rateThe limitations of the study include the small sample size and its retrospective nature. However, the strength of our study is the availability of data from patients who underwent a homogenous TS-CPC technique; 180° of ciliary body ablation was documented in all cases.In conclusion, a reasonable IOP reduction can be achieved with 180° cyclodiode photocoagulation in patients with refractory glaucoma. As such, 180° TS-CPC appears to be a safe alternative to the 360° circumferential technique with very low risk of adverse effects for glaucoma patients with a history of previous failed glaucoma surgeries and limited visual potential. The possibility of repeat treatment sessions and the likely need for postoperative glaucoma medications should be discussed with patients prior to TS-CPC to ensure realistic post-surgery expectations.


The main clinical manifestations are global developmental delay, intellectual disability, epilepsy, dysmorphic features, hypopigmented and/or hyperpigmented lesions, and multiple congenital anomalies. PKS is associated with tissue mosaicism, which is difficult to diagnose through peripheral blood sample by conventional cytogenetic methods and Here, we report five patients with PKS. We delineate their clinical phenotypes and we compare them with previously published cases. We used array Comparative Genomic Hybridization (aCGH) with DNA extracted from peripheral blood samples. The five patients have also been tested by conventional cytogenetics techniques.Four out of five patients showed tetrasomy 12p by aCGH. Three of the four patients have typical i(12p) and one of the four demonstrated atypical tetrasomy 12p. The percentage of mosaicism was as low as 20%. Our cohort exhibited the typical PKS phenotypes.Our results demonstrate the efficacy of aCGH for the diagnosis of PKS from DNA extracted from lymphocytes. Thus, for patients suspected of PKS, we recommend performing aCGH on lymphocytes at an early age before  proceeding to skin biopsy. aCGH on peripheral blood samples is sensitive in detecting low level of mosaicism and it is less invasive method than skin biopsy. We reviewed also the literature concerning the previously published PKS patients diagnosed by aCGH. Additionally, 12q12 specific probe (PR11‐478B9) was used for patient 3. Samples were taken from blood for patients 1, 2, 3, and 5 and from skin biopsy for patients 4 and 5.2.5Genomic DNA was isolated from peripheral blood leukocytes for all patients using a nucleospin blood L kit (Macherey‐Nagel GmbH & Co. KG), according to the manufacturer's protocol. The whole genomic aCGH procedure was performed following the manufacturer's instructions . The 180K slides were scanned on an Agilent DNA Microarray Scanner and images were extracted with Feature Extraction software (12.0.1.1). Data analysis was carried out with Cytogenomics v3.0.3.3. Before 2014, the Feature Extraction software used was the version (11.5.11) and the data interpretation analysis used Workbench v3.4.2.7. The following parameters were used for interpretation: ADM‐2, threshold: 5.0, window: 0.2 Mb, cutoff: 0.25. A copy number variation was validated if an abnormal log2 ratio was obtained for at least three contiguous oligonucleotides. The aCGH results were analyzed with the UCSC hg19 assembly.3Pallister–Killian syndrome was confirmed in the five patients. We used aCGH on peripheral blood sample in all patients, karyotyping and FISH on peripheral blood sample only in three patients , on skin biopsy only in one patient (patient 4), and on both in one patient (patient 5). The combined results from aCGH and conventional cytogenetic techniques demonstrated the presence of typical i(12p) in patients 1, 2, 4, and 5 and partial tetrasomy of distal 12p (12p13.33p12.1) and partial trisomy of proximal part of 12p and 12q (12p12.1q12) for patient 3.Array Comparative Genomic Hybridization on DNA extracted from lymphocytes showed the presence of tetrasomy 12p in mosaic state in four patients out of five. The mosaicism percentages in aCGH analysis were 20 for patient 1 , 28 for patient 2 , and 50 for patient 5  and one copy of 12p12.1q12 . The marker chromosome has been characterized by aCGH and the result has been confirmed by FISH. The patient has the classical phenotype of PKS. Nevertheless, she has neither diaphragmatic hernia nor cardiac defect. The patient is 3 years old and therefore could manifest seizures later on. Izumi et al.  publishe5PKS is tissue‐limited mosaicism due to tetrasomy 12p. Our cohort exhibits the typical phenotypes of PKS, including classic dysmorphic features, global developmental delay, epilepsy, hearing impairment, and strabismus. Here, we confirmed that aCGH on peripheral blood sample may be considered as a first‐tier method to use when the PKS is suspected especially at early age. Moreover, the use of aCGH on a blood sample might avoid the need for a skin biopsy. Finally, the characterization of unbalanced chromosomal aberration and marker chromosome is more efficient by aCGH, which provides high resolution.None declared. Click here for additional data file.


Cryptococcal meningitis (CM) is a leading cause of mortality among HIV-positive South Africans. Reflex cryptococcal antigen (CrAg) testing of remnant plasma was offered as a pilot prior to implementation in October 2016 in KwaZulu-Natal province. The national reflex CrAg positivity was 5.4% compared to 7.3% for KwaZulu-Natal.The aim of this study was to interrogate CrAg positivity by health levels to identify hotspots.Data for the period October 2016 to June 2017 were analysed. Health district CrAg positivity and prevalence were calculated, with the latter using de-duplicated patient data. The district CrAg positivity and the number of CrAg-positive specimens per health facility were mapped using ArcGIS. For districts with the highest CrAg positivity, a sub-district CrAg positivity analysis was conducted.The provincial CrAg positivity was 7.6%. District CrAg positivity ranged from 5.7% (Ugu) to 9.6% (Umkhanyakude) with prevalence ranging from 5.5% (Ugu) to 9.7% (Umkhanyakude). The highest CrAg positivity was reported for the Umkhanyakude (9.6%) and King Cetswayo (9.5%) districts. In these two districts, CrAg positivity of 10% was noted in the Umhlabuyalingana (10.0%), Jozini (10.2%), uMhlathuze (10.5%) and Nkandla (10.8%) subdistricts. In these subdistricts, 135 CrAg-positive samples were reported for the Ngwelezane hospital followed by 41 and 43 at the Hlabisa and Manguzi hospitals respectively.Cryptococcal antigen positivity was not uniformly distributed at either the district or sub-district levels, with identified facility hotspots in the Umkhanyakude and King Cetswayo districts. This study demonstrates the value of laboratory data to identify hotspots for planning programmatic interventions. Cryptococcal antigen (CrAg) reflex testing of specimens with a CD4 count of ≤ 100 cells/µl was implemented across a network of CD4 testing laboratories in South Africa.2 This followed the inclusion of CrAg screening in South Africa’s national HIV guidelines in 2015, following recommendations by the World Health Organization (WHO).4Cryptococcal meningitis (CM) is a leading cause of mortality among HIV-positive persons in South Africa.5 Within KwaZulu-Natal, district CrAg positivity ranged from 6.2% in Amajuba to 9.2% in King Cetshwayo district, with the Umkhanyakude district reporting the second highest CrAg positivity at 8.9%.5Since the national implementation of reflex CrAg screening in South Africa in October 2016, data collected by testing laboratories confirmed that nationally, about 10% of all CD4 samples tested had a count ≤ 100 cells/µl. These specimens were tested for CrAg using a lateral flow assay (LFA) . Both the percentage of samples eligible for CrAg testing and the percentage of CrAg-positive results vary considerably across the nine provinces in South Africa. Data from a previously reported study showed a CrAg positivity of 2.4% in the Northern Cape versus 7.3% in KwaZulu-Natal.6 There are 11 079 700 people living in the province representing 19.8% of the national population.7 The provincial HIV prevalence is 16.9% in 2016 compared to the national prevalence of 12.2%. The 2016 HIV infection rate in KwaZulu-Natal is 2.3%  among 1 622 870 million HIV-seropositive individuals (15–49 years of age) living in the province. An estimated 1 129 314 HIV-positive individuals are on ART with 69.5% coverage.6 Reflex CrAg screening was offered for the first time in KwaZulu-Natal at the Prince Mshyeni Memorial laboratory in July 2015 as part of a CrAg reflex testing pilot.9 By October 2016, all CD4 laboratories in KwaZulu-Natal offered reflex CrAg screening.KwaZulu-Natal is the second most populous province in South Africa and has the highest HIV prevalence.10 In that study, CM affected predominantly the economically active population .10 While 76% (n = 97) of patients knew their HIV status, but only 45% (n = 43) were on ART.10 Acute mortality was 55.9% (71/127) within 14 days of CM diagnosis highlighting the need for screening and preemptive treatment of subclinical cryptococcal disease before ART initiation.10 A 2007 study conducted at the Ngewlezane hospital reported that even in a setting where amphotericin B is available, the burden of CM deaths is particularly high in the immediate period after diagnosis (2.13 deaths per 100 person days).11 Of the 186 patients enrolled in this cohort, 52 (28%) died within 14 days of diagnosis.11 In 2015 the National Institute for Communicable Diseases reported 1745 laboratory-confirmed cases of CM from KwaZulu-Natal through its national network of clinical microbiology laboratories which participate in an active surveillance programme for pathogens of public health importance (GERMS-SA).12There are limited published CM data available for KwaZulu-Natal as most reported studies investigated selected health facilities with small case numbers. A study conducted at an urban district hospital between 2011 and 2012 reported that of the 127 patients with confirmed CM, 65 were men (51.2%).Given the higher-than-national average CrAg positivity in KwaZulu-Natal, the study reported here aimed to investigate CrAg positivity at the health district and sub-district levels with facility level investigation in the subdistricts with the highest reported positivity rates.Ethics clearance for this work was obtained from the University of the Witwatersrand . This study was conducted in accordance with relevant national and international guidelines. This study involved the secondary analysis of laboratory test volumes data that do not contain any patient identifiers. No patient recruitment was necessary as routine laboratory data was used for the study.Data reported here include reflex CrAg testing subsequent to a confirmed CD4 count ≤ 100 cells/µl using automated laboratory information system rules that identify eligible samples to be tested, that is, these data exclude provider-initiated CrAg screening. Owing to CD4 testing challenges at the Church of Scotland laboratory, all CrAg data from this laboratory were excluded for the purpose of this study. This laboratory serves the Umzinyathi health district that contributes only 22% of CrAg samples tested in this district.13 The de-duplicated data were used to identify both the number of patients receiving a CrAg test as well as the number with one or more positive CrAg tests to determine prevalence.13 The de-duplicated data provide a more accurate analysis of CrAg positivity for a given population.The data analysis includes both CrAg positivity using specimen-level data as well as CrAg prevalence after the data set was de-duplicated. The de-duplication process involved using the Corporate Data Warehouse (CDW)-assigned unique patient identifier that is determined through a probabilistic matching algorithm to identify if a patient had more than one CrAg test.CD4 and CrAg laboratory data were extracted from the National Health Laboratory Service (NHLS) CDW for the period October 2016 through to June 2017. Data were filtered to include only health facilities within KwaZulu-Natal. The data extract included the absolute CD4 count (< 100 cells/µl) and CrAg result. Additional data variables included the episode number, testing date, health facility location code and description, testing and referring laboratory names, date of birth, patient age (in years) and gender. The testing year and month were derived using the CD4 result review date. Ethics clearance for all CDW data extraction was obtained through the University of the Witwatersrand (M1706108). Data was de-identified at the CDW.The CDW data extract were imported into a Microsoft Access table . Queries were used to prepare the data for analysis. The CDW location code and description were mapped to the District Health Information System (DHIS) health facility descriptions; for example, Addington hospital was mapped to the DHIS organisational unit (OU) 5 short description ‘Addington Hosp’. For each CDW location, in addition to the OU5 facility name, the DHIS province (OU2), health district (OU3), health sub-district (OU4), OU type, latitude and longitude were added to the mapping table. Where a CDW location description was not matched to the DHIS list, it was marked as ‘excluded’ (e.g. Empangeni Prison). The ‘DHIS OU_Type’ was used to identify facility type, for example hospital , community health centre (CHC), or Primary health care clinic (PHC).The mapping table was loaded on Microsoft Access and added to the CD4 and CrAg query. The DHIS-mapped list was used to filter the data for legitimate health facilities. The list was also used to report data at the province, district and sub-district health care levels. The final data set was exported as a comma separated values (CSV) file for analysis in Stata SE  and Microsoft Excel .The CrAg positivity for KwaZulu-Natal was reported as the proportion of CrAg-positive samples divided by all samples (with CD4 count ≤ 100 cells/µl) with the 95% confidence interval (CI) reported. The provincial CrAg positivity was analysed across age ranges, gender, facility types and CD4 test ranges. The CrAg positivity was also assessed monthly to identify changes or patterns over time. A sub-analysis was undertaken for the provincial CrAg-positive samples to determine CD4 test ranges by facility type, gender and age category.CrAg positivity and prevalence was analysed for the 11 health districts in the province with the 95% CI reported . The total CrAg test volumes, number of positive CrAg samples and CrAg positivity was reported for each health district. Both the district CrAg positivity and prevalence are reported with 95% CI.ArcGIS was used to map the health district CrAg positivity as well as the number of CrAg-positive samples by health facility to identify where patients presented for care. The larger towns in the province were indicated on the map as reference points. The actual number of positive CrAg samples per health facility was reported in five categories: (1) 1–7, (2) 8–20, (3) 21–43, (4) 44–93 and (5) 94–148. Shapefiles were obtained from the municipal demarcation board and the DHIS spatial coordinates were applied for health facilities. District-level percentage of CrAg positivity was reported in four categories each allocated a different colour: (1) ≤ 5.7%, (2) 5.8% – 6.6%, (3) 6.7% – 8.1% and (4) 8.2% – 9.6%. Category ranges were automatically assigned based on actual data.The two districts with the highest CrAg positivity were identified and the respective sub-district and health facility CrAg positivity was reported using ArcGIS. The two district shapefiles were merged using the ArcMap data management toolbox. The percentage of CrAg-positive samples per health facility was reported using five categories: (1) 4.2% – 6.6%, (2) 6.7% – 8.7%, (3) 8.8% – 9.2% and (4) 9.3% – 10.87%. The actual number of positive CrAg samples per health facility was similarly reported in five categories: (1) 1–4, (2) 5–11, (3) 12–28, (4) 29–43 and (5) 44–135. Category ranges were automatically assigned based on actual data.p = 0.001). In the 16–19 years age group (n = 1415), the CrAg positivity was 8.2% (6.8% – 9.8%). A CrAg positivity of 8.4% was reported for both the 40–44 years (7.7% – 9.0%) and older than 49 years (7.7% – 9.1%) age groups. The lowest CrAg positivity was reported for the 15 years and younger group (4.9% [3.9% – 6.2%]) followed by the 20–25 years age group (5.7% [5.0% – 6.6%]). CrAg positivity was the highest for samples requested at hospitals at 10% (9.6% – 10.5%) compared to 6.5% (5.8% – 7.3%) and 5.7% (5.4% – 6.0%) for CHCs and PHCs respectively (p = 0.19). CrAg positivity was 12.4% (11.6% – 13.2%) for CD4 counts of ten cells/µl or lower. For the CD4 ranges of 11–29, 30–49 and ≥ 50 cells/µl, a CrAg positivity of 9.9% (9.4% – 10.5%), 7.4% (6.9% – 8.0%) and 5.2% (4.9% – 5.5%) was reported respectively (p = 0.21).For the reported period, 50 534 CrAg tests were performed  after exn = 17 017). The highest CrAg positivity was reported by the Umkhanyakude (9.6%), King Cetswayo (9.5% [8.7% – 10.4%]) and Zululand (8.1% [7.3% – 8.9%]) districts. The number of CrAg-positive samples per district ranged from 133  to 1304 (eThekwini). Following de-duplication, a provincial CrAg prevalence of 7.5% (7.3% – 7.8%) was reported. CrAg prevalence ranged from 5.5% (4.7% – 6.4%) to 9.7% (8.6% – 10.8%) for the Ugu and Umkhanyakude districts respectively. The highest CrAg prevalence was in the Umkhanyakude (9.7%), King Cetswayo (9.5% [9.0% – 10.8%]) and Zululand (7.9% [7.1% – 8.8%]) districts.CrAg positivity in the 11 districts ranged from 5.7% (Ugu [4.9% – 6.5%]) to 9.6% (Umkhanyakude [8.6% – 10.6%]) with an overall provincial CrAg positivity of 7.6% (7.3% – 7.8%) . For theAcross the province, 472 health facilities requested a CD4 test for which a reflex CrAg test was performed where the count was ≤ 100 cells/µl. CrAg-positive tests per health facility ranged from 1 to 146 .n = 120) in close proximity with CrAg-positive results were noted in the eThekwini district (Durban). The eThekwini district CrAg positivity was 7.7%. The number of CrAg-positive samples for this district ranged from one at smaller PHC facilities such as Merebank clinic to 146 at the Prince Mshiyeni Hospital. Two health facilities reported a CrAg positivity above 15%, that is, Mahatma Gandhi hospital (16.7%) and Blue Roof clinic (17.6%).A cluster of health facilities , iLembe, King Cetswayo (Empangeni/Richards Bay), Amajuba (Newcastle) and Ugu (Margate) districts with district CrAg positivity results of 6.5%, 7.3%, 9.5%, 6.2% and 5.7%, respectively. Three health facilities had between 94 and 146 CrAg-positive samples . There were 11 health facilities that had between 44 and 93 CrAg-positive samples identified, that is, RK Khan, Mahatma Gandhi, Madadeni, Edendale, Stanger, King Edward, Northdale, King Dinuzulu, Ladysmith and Benedictine hospitals as well as the KwaMashu Poly CHC. There were 27 health facilities with 21–43 CrAg-positive samples.n = 93) reported 28 or fewer CrAg-positive samples.As mentioned, the districts with the highest CrAg positivity rates were Umkhanyakude (9.6%), and King Cetswayo (9.5% [8.7% – 10.4%]). There are five subdistricts in the Umkhanyakude district compared to six subdistricts in King Cetswayo. Across the two districts, CrAg positivity ranged from 4.2% (Mthonjaneni) to 10.8% (Nkandla) . The Joz5 A statistically significant higher CrAg positivity was reported for males (p < 0.05). The majority of CrAg samples (33.7%) in the province were requested by health facilities in the eThekwini health district. District CrAg positivity ranged from 5.5% in Ugu to 9.7% for Umkhanyakude. Three districts reported a CrAg positivity ≥ 7.8% . Within the Umkhanyakude and King Cetswayo districts, the sub-district CrAg positivity ranged from 4.2% to 10.8%. Four subdistricts within these two districts reported a CrAg positivity between 9.3% and 10.8%.In this study, we describe a CrAg positivity of 7.6% [7.3% – 7.8%] for KwaZulu-Natal. This is the highest provincial CrAg positivity across South Africa.5 Across South Africa, a proportion of CD4 <100 cells/µl of 9.69% was reported.5 The provincial proportion of CD4 samples ≤100 cells/µl ranged from 7.33% for KwaZulu-Natal to 11.82% for Limpopo.5 In KwaZulu-Natal, the district proportion of CD4 samples ≤ 100 cells/µl ranged from 5.4% in Umkhanyakude to 9.1% in the Harry Gwala district. Consequently, this province was the last to implement CrAg screening. Given the data reported in this study, it is clear that CrAg prevalence data would have been a better proxy for the order of implementation. Unfortunately, at the time only the proportion of CD4 samples ≤ 100 cells/µl was available.The proportion of CD4 samples with < 100 cells/µl for the 2014–2015 financial period was used to prioritise the implementation of CrAg screening at the provincial and district levels.7 Over a third (33.5%) of the KwaZulu-Natal population reside in the eThekwini health district (n = 3.7 million) followed by uMgungundlovu (9.9%: 1.09 million) and King Cetshwayo (8.8%: 971 thousand).14 34.9% of the population are under 14 years of age,7 with 36.7% (n = 4 065 052) in the 16 to 34 years of age group. Overall, 71.6% of the provincial population is less than or equal to 34 years of age indicating a young population.7 The 2012 Human Sciences Research Council national household survey reported that most districts in the province had an HIV prevalence ranging from 16% to 22% with the exception of Umkhanyakude, Ilembe and eThekwini districts (ranging from 13% to 15%).15KwaZulu-Natal has a population of over 11 million people with an HIV prevalence of 16.9% , equating to a HIV-seropositive population of 1.8 million.6 By 2016, 1.06 million people were on ART (87% of HIV-positive people that know their status).6 Johnson et al. assessed the provincial progress towards the 90–90–90 targets and reported a provincial ART coverage of 62% compared to 57% nationally.16 To improve ART coverage, the province recently adopted the Universal Test and Treat (UTT) strategy in which all HIV-seropositive individuals receive ART regardless of CD4 count.6 The goal of the UTT strategy is to reduce the incidence of HIV infections.6 The CrAg burden revealed in this study is possibly linked to the significant burden of patients still to be initiated on ART or who disengage from HIV care.An analysis of the HIV-treatment cascade in the province in 2016 revealed that 23% of the HIV-seropositive population did not know their status, that is of the 1.8 million HIV-positive people 1.63 million knew their HIV status.17 The data are compressed and password-protected to maintain confidentiality.17 To receive the results for action reports, healthcare workers are required to apply online using the CDW self-service portal.17 Additionally, the laboratory data can provide indirect information about healthcare services that are being accessed by assessing what are being requested and from which health facility . The use of spatial tools allows for analysis at a glance by presenting the information in a way that makes it easy to visualise hotspots and further identify how homogenous or heterogeneous CrAg positivity is, for example. Aside from offering a broader public health perspective at the national level, due to linkage to specific geographical identifiers, the analysis enables drilling down to an individual health facility level to directly affect individual patient management or intervention.This study has demonstrated the inherent value of laboratory data to indicate how patients use and access services, to understand the burden of disease as evidenced in the study results and facilitate the identification of hotspots to guide programmatic interventions. This intrinsic value can be utilised at the national, provincial, district, sub-district and facility levels and even at the patient level and linked to service delivery or to a specific health programme. This is not possible with aggregate data systems. A good example is the results for action report that can deliver a list of babies that are HIV-positive to the district manager to ensure that they are linked to care.Specifically, in this study we have illustrated, with the outcomes reported here, how specimen-level laboratory data can be used to assess a laboratory test, CrAg, and establish the positivity at the provincial, district, sub-district and even at health facility levels. There was no bias or predominant area with higher testing numbers; we have shown that CrAg screening coverage appears to be widely  spread across the province, with 473 health facilities linked to at least one positively identified CrAg sample. The information also suggests that the implementation of the national reflex CrAg testing programme is facilitating CrAg testing from all health facilities through a CD4 test request to their local laboratory. The analysis has further revealed that CrAg positivity is not uniformly distributed at either the district or sub-district-level, with some districts demonstrating a much higher positivity; to effect meaningful clinical and programmatic impact at facility level, further investigation is needed to assess the positivity and assess whether a similar pattern could be anticipated at facility level as well. In this study we also reported the number of CrAg-positive samples at the health facility level. This approach enables programme managers to identify health facility hotspots to focus programme or clinical interventions that would assist in the identification of patients who are more likely to have cryptococcal disease before they become sick.Future directives and initiatives requiring coordination and collaboration by both the NHLS and the national, regional and provincial departments of health are needed, to ensure that patients are linked to care. Aside from the existing ‘results for action’ report of CrAg-positive patients that is issued at sub-district or facility level by the NHLS for individual patient follow-up, a more generalised collated data report about the volumes of patient accessing specific services, and how sick these patients are, is necessary. This report could be used to ensure that the original aim of the CrAg screening initiative is realised and that there is meaningful infrastructure and systems streamlined so that the follow-up of HIV-seropositive patients who additionally require antifungal treatment when diagnosed with early cryptococcal disease, receive this treatment.Information about patient outcomes where a positive CrAg result was reported were not available. There is, however, currently a planned collaboration between the National Institute for Communicable Diseases and the National Department of Health to undertake a prospective study. The purpose is to understand the outcomes of the SA CrAg screening initiative by following a CrAg-positive cohort from diagnosis to treatment. This will help to address some of the additional questions that cannot be answered solely with laboratory data. Additional questions that can be answered may be the loss to follow up, whether patients positively identified through the screening initiative receive treatment and what their clinical outcomes are. All CD4 samples tested for CrAg at the Church of Scotland laboratory were excluded from this analysis.