Background. Tuberculosis of the liver without active pulmonary or miliary tuberculosis is considered as an uncommon diagnosis. The aim of the present study was to determine the etiological role of tuberculosis in adult patients presenting with features of liver abscess. Methods. A total of 40 patients with liver abscess were included in the study. The liver abscess aspirate was subjected to microscopy, culture, and polymerase chain reaction to determine the role of tuberculosis as an etiological factor in liver abscess. Results. Of the 40 patients enrolled, 25% (10/40) were diagnosed with having tubercular liver abscess. In a total of 40 specimens, 2.5% (1/40) were positive for acid fast bacilli by Ziehl-Neelsen method, while 10% (4/40) were positive for M. tuberculosis by culture using BACTEC 460 and the yield increased to 25% (10/40) by polymerase chain reaction for M. tuberculosis. Conclusion. 25% of the patients presenting with liver abscess had tubercular etiology without features of active pulmonary or miliary tuberculosis. Liver can act as the primary site of involvement in the absence of activity elsewhere in the body. Tuberculosis should be considered as an important differential diagnosis of liver abscess irrespective of evidence of active tuberculosis elsewhere in the body. Tuberculosis can involve possibly all organs in the human body . Liver iTubercular liver abscess in itself is a rare entity. The disease mimics liver abscess of other etiology, and the diagnosis is frequently missed due to lack of suspicion. Despite reports of involvement of liver in miliary TB, demonstrated in the form of tubercular granulomas in liver tissues , 4, locaConventional methods for diagnosis of TB have been ineffective for peritoneal and liver TB; mean sensitivity of culture and AFB smear is 8.3–83% (depending on amount cultured and method utilized) and 3.2%, respectively . In some Mycobacterium tuberculosis (M. tb) as the etiological agent for liver abscess in adult patients with no evidence of active TB elsewhere in the body.Liver abscess has traditionally been ascribed to etiologies other than TB –10. The Forty consecutive subjects with clinical profile and radiological evidence of liver abscess from outpatient clinics, wards, and emergency departments of medicine at Lady Hardinge Medical College and Dr. Ram Manohar Lohia Hospital, New Delhi, were included in the study. Informed consent was obtained from each participant and clinical history collected.Patients were excluded from this study if they were hemodynamically unstable, required monitoring in intensive care units, were unable to undergo the requisite workup, and had uncontrolled coagulation defects. The clinical data obtained from each patient included (i) detailed medical history, (ii) clinical features, (iii) hematological laboratory profile like Hb%, leukocyte count, and erythrocyte sedimentation ratio, (iv) liver function test parameters, (v) Mantoux test reactivity, (vi) chest radiography, (vii) ultrasound examination of the abdomen, (viii) stool examination for ova/cyst, and (ix) serological tests for hepatitis B and hepatitis C and Human Immunodeficiency Virus (HIV). Entamoeba histolytica. The tubercular etiology of the liver abscess was diagnosed by Ziehl-Neelsen (ZN) staining for acid fast bacilli, culture by liquid culture (BACTEC 460), and detection of M. tb DNA using Mpt64 gene polymerase chain reaction performed on the liver aspirate.Patients underwent diagnostic ultrasound guided aspiration for liver abscess. The aspirate was subjected to gram stain, bacterial culture, and microscopy for trophozoites and cysts ofChi-square test was used to study the statistical significance of differences between patients with tubercular etiology and nontubercular etiology.Of 40 specimens, one (2.5%) was positive for acid fast bacilli by ZN method, while 4/40 (10%) were positive for M. tb by culture using BACTEC 460 (Becton Dickinson) and the yield increased to 10/40 (25%) by PCR for M. tb.The mean age of the patients in the study was 40.35 ± 13.03 years (mean ± SD) and of the tubercular liver abscess patients was 41.9 ± 13.57 years. Male to female ratio in the study was 4.7 : 1  and in tubercular group was 4 : 1. The predominant symptoms in the study, in both tubercular and nontubercular liver abscess patients, were fever and abdominal pain .p < 0.05) (Twenty percent of the patients in the study but 50% of the patients in tubercular group had past history of TB and had taken ATT ( < 0.05) . The fam2, 20.46 ± 2.99 in tubercular group, and 19.27 ± 2.29 in nontubercular group. Hepatomegaly was present in all, mean 5.45 ± 2.75 cm in the study, 4.84 ± 1.55 in tubercular group and 5.66 ± 3.04 cm in nontubercular group. The liver span in the study group was 16.53 ± 3.42 cm, in tubercular group 16.35 ± 2.54 and in nontubercular group 16.6 ± 3.7.The mean body mass index (BMI) in the study group was 19.93 ± 2.47 kg/mp < 0.05)  . Chest r Entamoeba histolytica in one patient who belonged to the tubercular group. Acid fast bacilli were not detected in the stool of any patient.On ultrasonography of the abdomen, majority of patients (82.5%) had only right lobe liver abscess, 7.5% had only left lobe liver abscess and 10% had abscess involving both the lobes. Stool examination for cysts/trophozoites showed cysts of Entamoeba histolytica.The viral serological markers for hepatitis B were detected positive in 5% patients in the nontubercular group, while none of the patients were positive for hepatitis C and HIV. The aspirated pus of all the patients was negative using Gram stain, bacterial culture, and microscopy for trophozoites or cysts ofSmear examination for acid fast bacilli and conventional culture techniques are the widely used methods of TB diagnosis. Acid fast smears in hepatic TB have shown higher frequency among miliary TB patients , 11. YamFever and abdominal pain were the predominant symptoms in the study and tubercular liver abscess group. The other symptoms were weight loss and jaundice, similar to previous studies in hepatic TB , 14, 15.On clinical examination, hepatomegaly was present in all the patients in the study; other studies , 14, 15 The liver function tests, though nonspecific, have been used to screen patients for hepatic TB. Some authors have shown raised serum-alkaline phosphatase (SAP) as suggestive of hepatic TB , 16, whiIn the present study, Mantoux test was positive in 22.5% and was statistically significant among tubercular group when compared with nontubercular group . Oliva eChest radiograph in the present study showed abnormalities in 20% study patients; only two belonged to the tubercular group; other studies have also reported normal chest X-rays in patients with local hepatic TB –23. SomeThe hypoechoic lesions and complex masses shown in ultrasound of the liver could not differentiate between liver abscess and carcinoma –28. Thou Entamoeba histolytica causing amebiasis. One-quarter of the study patients were clearly shown to have TB as the only etiology of the liver abscess; the abscess probably develops from coalescing caseating nodules as described by Oliva et al. [The study lent credence to the hypothesis that liver abscess can have etiologies other thana et al. . The stua et al. . It is i


Juvenile idiopathic arthritis (JIA) causes pain that may lead to posture and movement modifications and arouses muscular imbalance with reduced range of motion in the affected joints. Clinical assessment of the gait is difficult in children, because of the complexity and rapidity of movement. In children with JIA, the gait pattern is further complicated by subtle compensatory gait alterations in response to joint pain and limb deformity.To examine gait in children with joint involvement in knee who suffered from juvenile idiopathic arthritis (JIA) with video-based observation gait analysis.30 patients  were included in the study. Kinematic and time distance gait parameters were measured using a 10-meter walkway with separated 4 cm stripes in white and black color and a video camera. Sagittal plane views of cases  and the foreground and background views of walking (two views), a total of 4 views were recorded. After observing views in the normal speed, views were observed by using slowed down frame-by-frame viewing and the stop function. Time distance parameters and motion deviations in stance phase of gait were examined.The mean age was 9.63 ± 2.76 years (range 2-18 years). The mean disease duration was 4.41 ± 2.16 years (range 1-9 years). Patient population consisted of 11 patients with romatoid factor (+) polyarticular arthritis, 4 patients with romatoid factor (-) polyarticular arthritis, 12 patients with oligoarticular arthritis, and 3 patients psoriatic arthritis subtype. The mean of walking speed, step length, double step length and cadence were 0.51 m/s, 0.49 ± 0.07 m, 0.99 ± 0.14 m and 101 ± 25.33 steps/min respectively. The most noticeable changes in range of motion was increase of hip internal rotation(76.7%) and knee flexion(80%). Also, genu valgus incidence was 40%, genu varum was 20% and pes valgus was 36.7%.Gait is a parameter that should be considered in children with JIA. This study reported that the time-distance variables of children with JIA were decreased according to healthy peers in the literature. In the same time, we observed some gait deviations during the stance phase in lower extremity in children with JIA. These deviations are moderate or severe increase of hip adduction, hip internal rotation and knee flexion. Also we found genu valgus and pes valgus in static posture. We have identified these problems may relate to response to pain, avoidance harm to joints and some structural changes in joints.None declared.


Mass oral azithromycin distributions have dramatically reduced the prevalence of the ocular strains of chlamydia that cause trachoma. Assessing efficacy of the antibiotic in an individual is important in planning trachoma elimination. However, the efficacy is difficult to estimate, because post-treatment laboratory testing may be complicated by nonviable organisms or reinfection. Here, we monitored ocular chlamydial infection twice a year in pre-school children in 32 communities as part of a cluster-randomized clinical trial in Tanzania . We used a mathematical transmission model to estimate the prevalence of infection immediately after treatment, and found the effective field efficacy of antibiotic in an individual to be 67.6% (95% CI: 56.5–75.1%) in this setting. Sensitivity analyses suggested that these results were not dependent on specific assumptions about the duration of infection. We found no evidence of decreased efficacy during the course of the trial. We estimated an 89% chance of elimination after 10 years of annual treatment with 95% coverage. In vitro resistance has not been observed, although it is difficult to assess and rarely tested. Small surveys after one and after four mass azithromycin distributions have failed to find drug resistance  has targeted trachoma for elimination by the year 2020 . Repeatesistance .The efficacy of repeated oral azithromycin distributions has been reported at the community level . HoweverHere, we apply a mathematical transmission model to laboratory infection data from the Tanzanian portion of the Partnership for the Rapid Elimination of Trachoma trial (PRET ) to estiVillages were monitored as part of a cluster-randomized trachoma treatment trial in Tanzania  . In brieAll 32 villages were censused at baseline, 12, 24, and 36 months. One hundred randomly selected children aged 0–5 years were examined at baseline, and at 6, 12, 18, 24, 30 and 36 months after baseline. A dacron swab was passed 3 times over their inverted right upper conjunctiva, and processed for the presence of chlamydial DNA as previously described . The estThe study received ethical approval from institutional review board (IRB) of the Johns Hopkins University School of Medicine, the University of California San Francisco, and the Tanzanian National Institute for Medical Research, and was carried out in accordance with the Declaration of Helsinki. All subjects provided informed consent. The informed consent given was oral, because (1) verbal consent is the most ethical way to obtain consent, due to the high illiteracy rates in the study area, (2) IRB approved the use of the oral consent procedure for this study and (3) this oral consent is documented on the registration form for each study participant prior to examination in the field.l  for village j , and (2) the number of individuals reported to have been covered by antibiotics at treatment time point k .We modeled village chlamydial positivity rates at baseline, and at 6, 12, 18, 24, 30 and 36 months in each of 32 villages. The observed data consisted of (1) the number Chlamydia trachomatis over time, similar to models previously published . From village j with population size jN of which the number jY of infectives equals i, the probability P(jS = s|jY = i) that s positives are observed from a sample of size jM is given by j , we assumed a population of size jN, taken from the number of pre-school children found in the census at the time of treatment .Individuals were assumed to have been sampled at random. Let β. Moreover, we also assumed a constant exogenous force of infection ξ from outside the village . Finally, we assumed a constant per-capita recovery rate γ. Between periods of treatment, we assumed that the probability i infectives in the population at time t after treatment time point k obeys the following equations for each village j (suppressing the subscript for clarity):To model the change in prevalence between the prevalence surveys based on above assumptions, we used a classical SIS (susceptible-infective-susceptible) model structure, assuming that the force of infection is proportional to the prevalence of infection in the population with proportionality constant β is the transmission coefficient, ξ is the risk of infection from outside the village, γ is the recovery rate, i and N indicate the number of infective individuals and total population of the village at time t, and k is the time point of treatment.where j has probability k , where j receives treatment in the kth treatment; note that treatment is assumed to occur at a specific time for everyone. The antibiotic efficacy at treatment k is denoted as ke. We have assumed that the probability of treatment is independent of infection status, though some evidence indicates that individuals who do not participate in mass azithromycin-based anti-trachoma campaigns may have a somewhat lower risk of infection  is the beta function ; as a sj, we used the most recent census data to determine the village size jN. The initial condition is determined from j, the pre-treatment distributions of 1st, 2nd and 3rd treatments are j, i of infected individuals, we compute the probability of the observed data of treatment k in village j according toFor each village jM here denotes the sample size at the end of the period k, and τ is the interval between two observations). Specifically, the probability of the observed PCR-positive individuals after eachtreatment k in each village j can be represented as, i infections at 24 month (12 months after the 2nd treatment at 12 month), and i infections at 36 month (12 months after the 3rd treatment at 24 month)). Finally, we assume independent villages, so that the total loglikelihood at time τ months after each treatment k may be computed by summing over all 32 villages respectively ; previous models have estimated the recovery time to be from 3 to 12 months . Likelihood optimization was conducted using the Nelder–Mead downhill simplex method . We then estimated the efficacies e1, e2 and e3 for the first period (0–12 months), the second period (12–24 months) and the third period (24–36 months), respectively. For the base case scenario, we estimated the standard errors and confidence intervals of the estimated overall efficacy as well as the period specific estimates by using bootstrap resampling of villages. A 64-core parallel computing platform was used for bootstrap resampling . To test the hypothesis that there is no change in the efficacy over time, we first computed the efficacy for each village and time, and then used Page's L test of trend  from 3 to 18 months, assuming no inflow of infection (ξ = 0). We next allowed the rate of infection from outside the community, ξ, to be another unknown parameter to be estimated, and assumed the same values for the recovery rate to test whether the inflow of infection has influence on the estimated efficacy. To determine whether the method for initializing the ordinary differential equations could have affected our conclusions, we repeated the analysis assuming a uniform instead of the beta-binomial prior. For each of these, we used the leave-one-out jackknife method to evaluate the standard errors  to estiβ,γ) and the efficacy of the antibiotic estimated above, and varied the coverage level from 60% to 100% for all villages. Then, we simulated (100 replications for each village) the average prevalence for all villages within ten years of treatment. All computations were performed using the R statistical program  on the RTI MIDAS cluster (http://www.epimodels.org).Finally, to predict the critical coverage level (compliance) needed for eradication within 10 years, we used the transmission parameters  at baseline, 99.94 (SD 0.35) at 6-month, 99.72 (SD 0.99) at 12 months, 100 (SD 0.00) at 18 months, 99.97 (SD 0.18) at 24 months, 99.81 (SD 1.06) at 30 months, and 98.53 (SD 3.33) at 36 months. The estimated prevalence of ocular chlamydial infection by PCR at baseline was 22.0% , with standard deviation (SD) 10.1%. At 6 months the prevalence was 10.5% (SD 4.7%), at 12 months 13.0% (SD 6.4%), at 18 months 7.1% (SD 4.4%), at 24 months 8.6% (SD 7.3%), at 30 months 3.5% (SD 2.5%), and at 36 months 4.7% (SD 3.3%) . The meaγ is 1/6 month−1) (ê1), 65.9% (95% CI: 51.8–80.0%) for the second year (ê2), and 76.7% (95% CI: 63.5–89.8%) for the third year (ê3)  , we founear (ê3) . Using PSensitivity analyses for these findings are presented in As a final sensitivity analysis, we added the non-linear incidence term, and found the estimated common effective field efficacies  for three years were 66.9% (95% CI: 57.8–75.9%) with log-likelihood value of −530.682, 70.5% (95% CI: 62.3–78.6%) with log-likelihood value of −534.4659, 70.8% (95% CI: 62.6–79.4%) with log-likelihood value of −537.3769, and 60.9% (95% CI: 49.4–72.4%) with log-likelihood value of −532.483. These estimates are slightly lower than efficacies estimated with the linear term. Confidence intervals were derived using the jackknife method.Based on the above estimates for the efficacy in the base case scenario, we simulated trachoma transmission with constant efficacy over times in each village to derive the probability of elimination (defined as the absence of infection and transmission). With an antibiotic efficacy of 67.6% (95% CI: 56.5–75.1%) and a mean duration of infection of 6 months, we found that the elimination probability after 10 years treatment was 95.0% (SD 4.1%) assuming complete coverage, and 89.2% (SD 5.6%) with coverage of 95%. When coverage levels of 90%, 80%, 70% and 60% were assumed, we found the probability of elimination was 81.8% (SD 8.8%), 59.6% (SD 14.8%), 34.7% (SD17.5%) and 16.4% (SD 14.3%), respectively .Reff = exp((β–γ)τ)(1 – ec) < 1  (eff = 0.68) is higher than the critical efficacy level 52.6% needed for annual treatment to eliminate infection with perfect coverage , implying that annual mass treatment could eventually eliminate the infection.More generally, we may theoretically assess elimination by mass treatment by requiring sufficient coverage and efficacy that effective reproductive number fficacy) . The estAs sensitivity analysis of different infection durations, we also simulated trachoma transmission under three 10-year treatments with 12 months infection duration and the corresponding effective field efficacy of 70.7% (95% CI: 62.4–79.0%), 18 months infection duration and corresponding efficacy of 72.0% (95% CI: 64.0–80.0%), and 3 months infection duration and the corresponding efficacy of 62.5% (95% CI: 50.1–74.9%). Assuming complete coverage, the simulated elimination probabilities after 10-year treatments were 94.1% (SD 3.1%) for infection duration of 12 months, 94.4% (SD 3.6%) for infection duration of 18 months, and 94.1% (SD 4.2%) for infection duration of 3 months. When coverage levels of 95%, 90%, 80%, 70% and 60% were assumed, we found that the probability of elimination with infection duration of 12 months was 86.8% (SD: 7.6%), 73.6% (SD 11.4%), 40.9% (SD 18.3%), 15.4% (SD 15.0%) and 4.6% (SD 10.8%), respectively ; the probability of elimination with infection duration of 18 months was 85.6% (SD: 6.5%), 70.9% (SD 12.5%), 32.3% (SD 18.4%), 10.9% (SD 15.4%) and 2.9% (SD 8.9%), respectively ; the proApplying a transmission model to data collected from a 32-village, cluster-randomized trachoma elimination trial in Tanzania, we estimated an effective field efficacy of oral azithromycin in clearing the ocular chlamydial strains that cause trachoma. Specifically, we used a transmission model to find the efficacy of oral azithromycin most likely to have resulted in the observed data pre-treatment, 6 and 12 months after each treatment, given values for the coverage. This effective field efficacy was estimated to be 67.6%. This estimate is lower than the clearance rates of 92–98% which had been reported in genital chlamydia and assumed in previous trachoma transmission models . More reOne possible explanation for finding a lower efficacy estimate than previously found is the acquisition of macrolide resistance. If present, we would expect resistant strains to be selected for with the first mass treatment, and a progressively lower observed efficacy with each mass treatment. There were a few villages treated in previous years going back to 1999, but no Kongwa-wide mass treatment until the start of the PRET study .Our estimate may be biased for several reasons. Our base case model assumed that transmission is proportional to the number of infectious cases and number of susceptible cases (mass action); if this is not the case, then this may have masked increased transmission at the later, lower prevalence . SimilarWe modeled infection from outside the population of children in each community using a simple constant exogenous infection rate. Such exogenous infection may represent introduction from outside the community, or a first approximation to infection from older children or adults within the same community. Of course, such models could be further refined to reflect age structured transmission dynamics. In this setting, the other age groups (older children and adults) were being treated as well, and other studies have shown consistently higher prevalence in small children than in other age groups e.g. . PreviouIn our model, the transmission coefficient is determined by the constellation of factors which affect transmission. To the extent that transmission is reduced by the F and E components of the SAFE strategy, the estimated transmission coefficients would be smaller. Face washing  and enviModels have predicted that with high coverage of an efficacious antibiotic, repeated distributions can eliminate infection from even the most severely affected communities . Longitu12F1F2F3


This study aimed to assess follicle survival after xenotransplantation ofsheep ovarian tissue into male and female immunodeficient rats. We evaluated the effectsof gonadotropin treatment on follicular development in the transplanted tissue.2) levels were measured before and after gonadectomy, andat the end of the experiment. The control group consisted of 7 male and 7 female noncastrated/non-grafted rats and the sham group comprised 7 male and 7 female castrated/non-grafted rats for comparison of serum E2 concentrations.In this experimental study, sheep ovarian cortical strips weretransplanted into the neck back muscles of 8 male and 8 female immunodeficient, castrated rats. Fourteen days after surgery, each rat was treated with human menopausalgonadotropin (hMG) for 9 weeks. One day after the last injection, ovarian tissues wereremoved and fixed for histology assessment. Histology analyses were performed beforeand after grafting. Estradiol .The percentage of primordial follicles decreased after transplantation in male(25.97%) and female (24.14%) rats compared to the control group . Preantral follicles increased in the male (19.5%) and female (19.49%)transplanted rats compared to the control group (11.4%). Differences in antral folliclesbetween male (0.06 ± 0.0%) and female (0.06 ± 0.0%) rats were not noticeable comparedto control (1.25 ± 0.0%) rats. We observed a significantly higher percent of mean E2 secretion between xenografted maleand female rats, we observed no statistical differences in terms of follicular development.Despite significant differences in E Transplantation of a reproductive organ is one treatment for sterility. Transplantation of vitrifiedwarmed ovarian tissue from the donor female to herself can revive fertility. Inability to transplant ovarian tissue from the donor female or risks of disease relapse often prohibit autotransplantation ,3. XenotThe present study aimed to determine the optimal transplant conditions for maintenance, growth and maturation of follicles after xenotransplantation of fresh ovarian tissue from sheep into immunodeficient rats. We evaluated the ovarian tissue response to exogenous gonadotropin stimulation. To follow-up the current experimental study, all chemicals were purchased from Sigma ( USA ) and Gibco , with the exception of hMG and human serum albumin ( HSA ) which were procured from Organon, Oss, Holland and from Biotest, Germany, respectively. All animal procedures were approved by the Ethical Committee at Royan Institute. Sheep ovaries were procured from a slaughterhouse in Shahriar ( Iran ). Ovaries were transported in phosphate buffered saline medium  supplemented with 50 mg/ml streptomycin and 60 IU/ml penicillin ( Gibco ) at 39˚C. In the laboratory, the ovaries were washed three times with fresh DPBS and placed on a sterile Petri dish that contained HEPES tissue culture medium ( HTCM ) supplemented with 10% HSA. Next, we separated the medulla from the cortex. The cortex was cut into slices with approximate dimensions of 1 mm ( length )×2 mm ( width )×2 mm ( thickness ). Sections were placed in fresh HTCM medium supplemented with 10% HSA. The ovarian pieces were washed three times with TCM. One or two pieces of ovarian cortex were fixed in Bouin’s solution as a fresh control for morphological and functional analyses . 2) concentrations. We evaluated the host gender  on follicular development in xenografted sheep ovarian tissue. In this study, 8 sheep ovaries were used. Each ovary was segmented into 3 parts and divided into 3 groups, a control ( intact nongrafted ) and two experimental . The control group consisted of 7 male and 7 female noncastrated/non-grafted rats and the sham group comprised 7 male and 7 female castrated/nongrafted rats for comparison of serum estradiol  to their drinking water for five days before xenotransplantation of the ovarian tissues. The rats remained on the same immunosuppressant throughout the experiment. Rats had free access to sterilized food and water. Serum levels of cyclosporine with the average of concentration 1750 ± 34 ng/ml were measured in a random sample of rats . The immunosuppressed rats were anesthetized with intraperitoneal ( i.p. ) injections of 50 mg/kg bodyweight of 10% ketamine  and 5 mg/kg xylazine . Gonadectomy was performed through a dorsomedian incision in female rats and through a ventromedial incision in male rats. For transplantation, we used anesthetized, castrated rats. Surgery procedures were carried out under a laminar flow hood under aseptic conditions. One piece of ovarian tissue was placed in each rat’s neck muscle. The muscle was subsequently sutured with absorbable thread. Each female and male rat received i.p. injections of hMG ( 5 IU FSH / 5 IU LH ) every second day starting from day 14 after transplantation for 9 consecutive weeks. This dose was adjusted from an earlier study by Kagabu and Umezu . 2 levels before and after the gonadectomy,and at the end of the experiment. Ratswere anesthetized, after which 800-1000 μl ofblood was obtained using an orbital sinus puncturetechnique for E2 measurement. Blood wasallowed to clot at room temperature (24˚C) for30 minutes, and then centrifuged at 3000×g for 5minutes for serum collection. E2 was determinedby an ELISA Kit (ABIN416279) according to themanufacturer’s instructions.We measured EOvarian tissue from the experimental  and control ( intact non-grafted ) groups were fixed in Bouin’s solution, embedded in paraffin wax, serially sectioned at 6 μm, and stained with hematoxylin and eosin. The numbers of morphologically normal and degenerated follicles were counted in all prepared slides from each group, which included 24 total sections. All sections were studied using a light microscope  at a magnification of ×200. According to Liu et al.  "follicl2 concentrations in each group were analyzed using oneway ANOVA. Numbers of follicles between experimental groups were analyzed according to the Kruskal-Wallis test. A value of P<0.05 was considered statistically significant. Percentages of growing follicles and ETissue from 16 sheep ovaries were transplanted into 16 gonadectomy rats . However, after surgery, 7 male and 6 female rats survived. Therefore we evaluated tissue from 7 control group ovaries ( ovarian tissue non-transplanted ), 6 ovaries transplanted into female rats, and 7 ovaries transplanted into male rats. Histological assessment of the ovarian tissues showed a non-significant decrease in the percentage of primordial follicles in the XM ( 25.97 ± 0.03% ) and XF ( 24.14 ± 0.03% ) groups compared to the control group ( 37.51 ± 0.05% ). The percentage of primary follicles non-significantly increased in both the XM ( 47.7 ± 0.03% ) and XF ( 48.85 ± 0.04% ) groups compared to the control group ( 43.22 ± 0.04% ). The lowest percentage of preantral follicles was in the control group ( 11.4 ± 0.03% ) compared to the XM ( 19.5 ± 0.02% ) and XF ( 19.49 ± 0.02% ) groups. There were no significant differences in preantral follicles between the groups. There was no significant difference in terms of follicle degeneration among the groups , Fig.1. 2 levels( pg/ml ) between the XM ( 45.44% ) and XF ( 33.36% ) groups. The XM group ( 45.44% ) compared to the sham male ( 22.71% ) and female ( 25.96% ) rats significantly differed . However, this supposition did not apply in our study because the gonads were removed along with transplantation in both male and in female immunodeficient rats. In addition, hMG hormone injection in castrated male rats affected the hypothalamus and caused the secretion of gonadotropin-releasing hormone ( GnRH ). This hormone subsequently stimulates the pituitary gland and causes a normal rate LH and FSH secretion, whereas increasing hormone dosage in castrated female rats may stop or slow down the hormonal cycle. The percentage of follicles between transplanted groups and the control group showed no significant difference. The percent mean E 2 value (pg/ml) between xenografted male and female rats, weobserved no statistical difference in terms of folliculardevelopment. We found no justification forfollicular development and increasing E2 levels.Despite significant differences in E2 and a better survival rate, are likelyto be better candidates for supporting ovarianxenotransplantations compared to castrated femalerats.In general, castrated male rats, due to increasedlevels of E


Among the estimated 1.2 million persons living with human immunodeficiency virus (HIV) infection in the United States, approximately 14% have not had their HIV diagnosed . CDC anaIn 2013, CDC funded 61 health departmentsValid HIV tests are records in which data on test technology  or test result  or both are reported. Persons who test positive for HIV and report no prior positive test results are categorized as new positives. Linkage to HIV medical care is defined as attendance at first medical appointment within 90 days of the current test date. Attendance at first medical appointment can be confirmed by client report, HIV care provider report, or HIV surveillance record check. To account for missing data on linkage to care, both minimum and maximum percentages were calculated.HIV testing records submitted to CDC by June 2, 2014, were analyzed and stratified by 23 site types in health care and non–health care settings,**In 2013, a total of 3,343,633 CDC-funded HIV tests were conducted in the United States; HIV test setting data were available for 3,276,594 (98.0%). In health care settings, the highest percentages of tests were conducted in primary care clinics (27.2%), STD clinics (25.6%), emergency departments (15.0%), other health care settings (12.8%), and correctional facilities (10.5%). The percentage of new positives ranged from 0.2% to 0.8% and was highest in STD clinics (0.8%), unspecified outpatient facilities (0.5%), substance abuse treatment facilities (0.4%), HIV clinics (0.4%), and inpatient facilities (0.4%). In non–health care settings, the highest percentage of tests were conducted in HIV counseling and testing sites (46.7%), other non–health care settings (20.5%), and community settings (13.8%). The percentage of new positives ranged from 0.2% to 1.3% and was highest for partner services field visits  (1.3%); bar, club, or adult entertainment venues (1.2%); individual residences (1.1%); and HIV counseling testing sites (1.0%) .No HIV testing site met the National HIV/AIDS Strategy goal of 85.0% linked to HIV medical care within 90 days of diagnosis based on the minimum percentages calculated. However, using the maximum percentages calculated, the goal was met by eight of the 12 site types among health care settings, including all except for the following: unspecified outpatient facilities (0.0%), HIV clinics (19.4%), women’s health clinics (57.1%), and TB clinics (72.2%). STD clinics identified the largest percentage of new positives (0.8%) among all health care settings and also met the National HIV/AIDS Strategy linkage goal. The linkage goal also was met by seven of 11 site types in non–health care settings, including all except for the following: community settings (67.7%), individual residences (63.6%), public areas (78.7%), and syringe exchange programs (61.5%). HIV counseling and testing sites identified the largest number of new positives linked to HIV care  .The percentage of new positives identified in different setting types ranged from 0.0% to 0.8% among whites, 0.2% to 2.3% among blacks, and 0.1% to 1.3% among Hispanics for both health care and non–health care settings. Within health care settings, the highest percentage of new positives among whites was found in STD clinics (0.5%) and unspecified outpatient facilities (0.4%), among blacks in STD clinics (0.8%) and substance abuse treatment facilities (0.7%), and among Hispanics in STD clinics (1.0%) and dental clinics (0.5%). In non–health care settings, the highest percentage of new positives was found in bar, club, or adult entertainment venues among blacks (2.3%), Hispanics (1.3%), and whites (0.8%); partner services field visits among blacks (2.0%) and whites (0.8%); individual residences among Hispanics (1.2%); and HIV counseling testing sites among whites (0.8%) .In non–health care settings, among target populations, for MSM, the percentage of new positives ranged from 0.6% in syringe exchange programs to 5.8% in partner services field visits. For heterosexual men, the percentage of new positives ranged from 0.1% in bar, club, or adult entertainment venues to 0.8% in partner services field visits. For heterosexual women, the percentage of new positives ranged from 0.1% in school or educational facilities and other non–health care settings to 0.7% in partner services field visits. Other settings with the highest percentage of new positives included other non–health care settings for MSM (3.7%), community settings for heterosexual men (0.6%), individual residences for heterosexual women (0.6%), and HIV counseling and testing sites for MSM (2.7%) and heterosexual men (0.5%) .SummaryWhat is already known on this topic?CDC recommends routine screening for human immunodeficiency virus (HIV) infection in health care settings for persons aged 13–64 years in areas where prevalence is ≥0.1% and for persons at increased behavioral or clinical HIV risk in non–health care settings. Targeting HIV testing and prevention efforts toward high-risk groups in non–health care settings has been shown to be necessary to identify persons with undiagnosed HIV and link them to medical care.What is added by this report?In 2013, the percentage of newly identified HIV-positive persons varied widely among sites in health care settings . In non–health care settings, HIV counseling and testing sites conducted the most HIV testing and identified the largest number of new positives , for a positivity percentage of 1.0%.What are the implications for public health practice?These findings highlight the importance of examining program data by settings and sites to better understand which are most effective at reaching persons with undiagnosed HIV among the most affected populations and for informing decisions about program planning and allocation of HIV testing resources.STD clinics identified a higher percentage of persons with new diagnoses of HIV infection (0.8%) compared with other health care settings (0.2%–0.5%). New positives identified in non–health care settings ranged from 0.2% to 1.3% overall, 0.3% to 2.3% among blacks, 0.2% to 1.3% among Hispanics, and 0.6% to 5.8% among MSM. The findings indicate that certain site types yield higher percentages of diagnoses among persons who were previously unaware of their HIV infection. They also highlight the importance of local and national program monitoring and evaluation efforts to determine which sites are most effectively providing HIV testing, identifying new positives, and linking new positives to care. Linkage to care percentages within 90 days were low for certain site types (unspecified outpatient facilities and HIV clinics) because some persons were linked after 90 days. Additionally, data from these two site types each represent a single jurisdiction and might not reflect the national linkage percentages for these types of testing sites. These findings might enable health departments and community-based organization programs to effectively allocate HIV testing resources by testing site.Although testing in non–health care settings identified a higher percentage of new positives, such testing often is more expensive per test than testing in health care settings and might not target all hard-to-reach populations. Conversely, health care settings, which offer more efficient methods of testing and linkage, might miss undiagnosed HIV-positive persons who do not access health care.The findings in this report are subject to at least three limitations. First, monitoring linkage is challenging. Because of missing data, minimum and maximum percentages were calculated for linkage to care; therefore, the actual percentages lie somewhere between these two values. Second, because this report focuses only on CDC-funded HIV tests, these findings are not generalizable to the entire U.S. population. Finally, because determination of new positives was based on self-report of no prior positive test results, the number of new positives might be overestimated.Continued efforts to target HIV testing toward high HIV prevalence areas and populations at high risk can facilitate diagnoses of new positives. For example, CDC’s Expanded HIV Testing Initiative, which targets testing toward jurisdictions with a high proportion of AIDS diagnoses among blacks, has shown a significant return on investment in HIV testing, diagnosing new positives, and averting new infections . Activit


M. tuberculosis strains circulating in selected communities in Ethiopia as well as to evaluate the drug sensitivity pattern of these strains.The identification of circulating TB strains in the community and drug sensitivity patterns is essential for the tuberculosis control program. This study was undertaken to identify M. tuberculosis from previous study were typed using region of difference (RD) 9-based polymerase chain reaction (PCR) and spoligotyping. Drug sensitivity testing was conducted using the indirect proportion method on Lowenstein-Jensen media.This study was a continuation of the Ethiopian National TB Prevalence Survey that was conducted between 2010 and 2011. Culture-positive isolates of M. tuberculosis by RD9-based PCR and spoligotyping of 91 of these isolates leds to the identification of 41 spoligotype patterns. Spoligotype revealed higher diversity (45 %) and among this 65.8 % (27/41) were not previously reported. The strains were grouped into 14 clusters consisting of 2–15 isolates. The dominant strains were SIT53, SIT149 and SIT37 consisting of 15, 11, and 9 isolates, respectively. Our study reveals 70 % (64/91) clustered strains and only 39.1 % (25/64) occurred within the same Kebele. Further assignment of the strains to the lineages showed that 74.7 % (68/91) belonged to Euro-American lineage, 18.6 % (17/91) to East Africa Indian lineage and the remaining 6.5 % (6/91) belonged to Indo-oceanic lineage. Valid drug susceptibility test results were available for 90 of the 92 isolates. Mono-resistance was observed in 27.7 % (25/90) and poly-resistance in 5.5 % (5/90) of the isolates. Moreover, multi-drug resistance (MDR-TB) was detected in 4.4 % of the isolates whilst the rest (60/90) were susceptible to all drugs. The highest level of mono-resistance, 26.6 % (24/90), was observed for streptomycin with majority (91.1 %) of streptomycin mono-resistant strains belonging to the Euro-American lineage.All 92 isolates were confirmed as M. tuberculosis circulating in selected sites of Ethiopia were identified along with the drug sensitivity patterns. Thus, these findings are useful for the TB Control Program of the country.In this study, the strains of  There are an estimated 9 million new cases of TB every year. TB is the second leading cause of death from an infectious disease worldwide and is responsible for 1.5 million deaths annually. Control of TB is becoming a challenge to the endemic countries due to the emergence of drug resistance. Recently, the WHO Global TB Report estimated that total of 480,000 people developed MDR-TB worldwide in 2013. The prevalence of MDR-TB has been estimated to be 3.5 % in newly diagnosed cases and 20.5 % in previously treated TB cases [In Ethiopia, TB is a major public health problem and the WHO categorizes Ethiopia as a high TB and MDR-TB burden country . The firMycobacterium tuberculosis (M. tuberculosis) strains circulating in Ethiopian communities and evaluation of the drug sensitivity patterns of these strains is useful for the TB control program in the country. Since the study was done on positive cultures isolated from community-based survey, those patients who have low health seeking behavior were mostly captured. Therefore, this study was undertaken for the identification of the M. tuberculosis strains circulating in selected communities in Ethiopia and thereafter to evaluate the drug sensitivity pattern of these strains.Knowledge on the This study was a continuation of the Ethiopian National TB Prevalence Survey that was conducted between 2010 and 2011. The participants for the prevalence survey carried out by Kebede AH and colleagues were recruited from 85 Kebeles (communes), selected from 85 Woredas (districts) which were stratified as urban, rural and pastoralist population. The number of Kebeles covered in rural, urban and pastoralist areas were 63, 14 and 8 respectively. Sample size determination for the prevalence survey is reported elsewhere [ The spatial distributions of the selected study sites are displayed at Woredas level Fig. .Fig. 1SpThe laboratory analysis was carried out from July to December 2012. For this study, deletion typing, spoloigotyping and drug susceptibility testing were done on positive isolates. Culture and identification of the isolates for the prevalence survey were performed using 4 % NaOH and Capilia test respectively.M. tuberculosis complex from other mycobacterial species was performed using Capilia test. The test is based on the M. tuberculosis antigen MPB64, which is specific to the members of the M. tuberculosis complex. Testing and interpretation of the assays was done according to the manufacturer instruction [Equal amounts of 4 % NaOH were added to sputum in a 50 ml screw capped tube. The mixture was vortexed for 1–2 min and kept for 15 min at room temperature. Sterile phosphate buffer (pH =6.8) was added up to 45 ml and then centrifuged at 4 °C for 15 min at 3000 g. After decanting the supernatant, a few drops of sterile phosphate buffer (pH =6.8) was added to reconstitute the sediment. An aliquot of 100–200 μl of the sample sediment was then inoculated into two bottles of Löwenstein- Jensen (LJ) media. The inoculated media was incubated at 37 °C. Bacterial growth was checked for contamination and fast growers in first week and followed weekly up to 8 weeks. Cultures with no growth until the eighth weeks were recorded as negative [M. tuberculosis from the other members of the M. tuberculosis complex species was done using region of difference (RD)-9 polymerase chain reaction. RD9-PCRdeletion typing was performed on heat-killed cells to confirm the presence or absence of RD9 using three primers RD9flankF, RD9IntR and RD9flankR [et al. using a commercially available kit . Interpretation of the result was based on differences in molecular weight. A molecular weight of 396bp was considered as M. tuberculosis or M. canettii, while a molecular weight 575bp was considered M. bovis or M. africanum [Identification of D9flankR . PCR ampM. tuberculosis was done using spoligotyping as previously described by Kamerbeek and colleagues [M. tuberculosis chromosome. The DR region was amplified using primers DRa (GGTTTTGGGTCTGACGAC) and DRb (CCGAGAGGGGACGGAAAC). Spoligotyping was performed with a commercially available kit according to the manufacturer instructions . Lineage and SIT  number assignment was done using SPOLD4 and SPOTCLUST [Strain typing of lleagues . The PCRPOTCLUST .Drug susceptibility testing (DST) was performed for first line drugs; isoniazid, streptomycin, rifampicin and ethambutol, using indirect proportion method on Lowenstein–Jense media. The critical concentration for each drug was 0.2μg/ml, 4μg/ml, 40μg/ml and 2μg/ml for isoniazid, streptomycin, rifampicin and ethambutol respectively. Result interpretation was done by comparing growth on control media and media containing drug. If more than 1 % of the test population was observed on the drug containing media, the result was interpreted as resistant to that drug P values of 0.05 or less were regarded as significant.Statistical analysis was carried out using SPSS software packages. Patient characteristics for differences in proportions were compared. The chi square test was used to assess statistical significant difference. The laboratory analysis was done on stored culture positive samples. Specific patient identifiers were not used for this study. Ethical clearance was obtained from Scientific and Ethics Review Committee at Ethiopian Public Health Institute.The mean age of culture positive participants was 34.4 years 95 % CI 31.2–37.7). The overall culture positivity rate was 1.6 % (96/5863). The distribution of culture positivity across the categories of background characteristics of TB suspects is summarized in Table .2–37.7. M. tuberculosis complex based on Capilia TB immunochromographic assay, 4 samples were excluded from RD9-PCR analysis (2 isolates failed to grow after re-culturing and 2 cultures were not retrieved). The remaining 92 isolates were analyzed based on region of difference analysis. RD9 analysis showed that 92 isolates contained an intact RD9. This indicated that the 92 isolates were Mycobacterium tuberculosis species or M. canettii.Out of 96 isolates positive for M. tuberculosis were SIT53 (15/91), SIT149 (11/91) and SIT37 (9/91). Our study reveals 70 % (64/91) clustered strains of which 53 were registered in the international database whereas 11 were newly identified. Cluster formation within Kebeles was observed only 39.1 % (25/64)  were not previously reported. The isolates were grouped into 14 clusters consisting of 2–15 isolates each. The dominant strains of 7/41 wereP = 0.287). Among the four MDR-TB detected, three of them were isolated from young patients (age ranges 16–20). The lineage of those MDR TB cases showed that three of them belonged to East Africa Indian lineage and one belonged to the Euro-American lineage.Valid DST results for all first line anti-TB drugs were available for 90 isolates Table . Two isoTuberculosis (TB) is the most common opportunistic infection in HIV positive patients and TB can occur at any time during the course of HIV infection . This stM. tuberculosis although some cases are caused by M. bovis. In this study, RD9deletion typing was used to differentiate between M. bovis and M. tuberculosis [M. tuberculosis. The absence of M. bovis among the isolates collected from rural communities was unexpected and contradicts with the earlier studies [M. bovis requires further study and may be due to the manifestation of M. bovis in extra-pulmonary TB.Most of human TB is caused by rculosis , 13. Eve studies , 15. TheM. tuberculosis occurs in relatively closed populations but in a rural setting the presence of clustering often is not associated with recent transmission; it could be the result of reactivation of remote infections acquired years or decades earlier.Cluster formation and epidemiological links have been used to qualify recent transmission . Our finUnderstanding the prevalence of TB drug resistance offers an opportunity to assess the extent of resistant bacteria transmission in the community as well as evaluate effect of the National Tuberculosis Program . The MDRM. tuberculosis circulating in selected sites of Ethiopia were identified along with the drug sensitivity patterns. More than 83 % of the population is living in rural areas of Ethiopia. Since declining incidence of TB is expected with decreased clustering, coupling case detection and treatment alone in those large portions of the rural population will have a huge contribution to the reduction of TB. Besides, TB and MDR rate in young was high but with such small number of cases the possible relationship is inconclusive it needs further study.In this study, the strains of


Clinical examination of trachoma is used to justify intervention in trachoma-endemic regions. Currently, field graders are certified by determining their concordance with experienced graders using the kappa statistic. Unfortunately, trachoma grading can be highly variable and there are cases where even expert graders disagree . Prior work has shown that inclusion of borderline cases tends to reduce apparent agreement, as measured by kappa. Here, we confirm those results and assess performance of trainees on these borderline cases by calculating their reliability error, a measure derived from the decomposition of the Brier score.We trained 18 field graders using 200 conjunctival photographs from a community-randomized trial in Niger and assessed inter-grader agreement using kappa as well as reliability error. Three experienced graders scored each case for the presence or absence of trachomatous inflammation - follicular (TF) and trachomatous inflammation - intense (TI). A consensus grade for each case was defined as the one given by a majority of experienced graders. We classified cases into a unanimous subset if all 3 experienced graders gave the same grade. For both TF and TI grades, the mean kappa for trainees was higher on the unanimous subset; inclusion of borderline cases reduced apparent agreement by 15.7% for TF and 12.4% for TI. When we assessed the breakdown of the reliability error, we found that our trainees tended to over-call TF grades and under-call TI grades, especially in borderline cases.The kappa statistic is widely used for certifying trachoma field graders. Exclusion of borderline cases, which even experienced graders disagree on, increases apparent agreement with the kappa statistic. Graders may agree less when exposed to the full spectrum of disease. Reliability error allows for the assessment of these borderline cases and can be used to refine an individual trainee's grading. Trachoma is the leading infectious cause of blindness and the World Health Organization plans to eliminate it as a public health concern worldwide by the year 2020. This effort in large part involves mass oral antibiotic distributions to communities. A simplified trachoma grading scale is used to assess presence of active infection. Field workers must be properly trained and certified to perform these eye exams because their findings inform when to start and stop community-wide antibiotic treatments. Certification involves measuring agreement in trachoma grades between a trainee and an experienced grader on a test-set of trachoma photographs. Often, these test-sets have hard-to-grade cases of trachoma removed. We found that removing these borderline cases inflates agreement. Including these borderline cases in the test-set allows a more realistic estimate of agreement, but it is still difficult to assess a trainee's grades for cases which even experts disagree on. We found that reliability error, a measure derived from the decomposition of the Brier score (the mean squared error of a set of forecasts), can be used to assess a trainee's evaluation of these borderline cases. Chlamydia trachomatis, the causative agent of trachoma, are relatively expensive and rarely performed in trachoma-endemic areas, so the clinical examination will likely remain important in the future The World Health Organization (WHO) recommends clinical examination of the upper tarsal conjunctiva of children for trachoma to determine when to start and stop mass antibiotic distributions, and when to declare elimination as a public health concern Clinical grades are assigned using the WHO's simplified grading system, which has 2 grading classes instead of 4, as compared to its predecessor. The simplified grading system was developed for use by trained non-specialist personnel to obtain reliable information on trachoma in population-based surveys or for the simple assessment of the disease at the community level. Trachoma programs almost universally use the simplified system. While its predecessor is able to more finely discern disease activity, it requires more training to use accurately reliability error, a measure derived from the decomposition of the Brier score, can assess grading in these marginal cases.Agreement with experienced trachoma graders using a kappa statistic is the most common method currently used for certifying competence of field graders The Brier Score is the mean squared error of a set of predictions. It can be decomposed into three terms: reliability error, resolution, and uncertainty. Reliability error measures how often a set of predictions given the same forecast probability came true. Resolution measures whether different classifications of forecasts in fact had different outcomes, and uncertainty measures the variance of the outcomes, having nothing to do with the forecasts themselves. Decompositions of the Brier score have been used in meteorology to assess accuracy of weather forecasts The Partnership for the Rapid Elimination of Trachoma (PRET) was a three-country community-randomized trial  which evaluated different mass antibiotic treatment regimens for trachoma During the PRET baseline visit, in Spring 2010, three trained photographers took two or more photographs of the upper right everted conjunctiva of each study participant in the 48 communities with a Nikon D-series camera with a Micro Nikkor 105 mm f/2.8 lens . Of the 48 communities in PRET, 6 met inclusion criteria for this study, having a prevalence of TF between 40% and 60% among children aged 0–9. The mean pre-treatment TF prevalence in these communities was 51.4%. In total, approximately 1800 photographs were taken of 590 children from these 6 communities. Of those photographs, 200 (11%) were selected for inclusion in this study because they were well focused, centered, and without excessive tears. Specifically, photos were not chosen based on clinical activity, so they presumably represented the entire spectrum of disease including borderline WHO grades.The 200 photos were compiled into an examination to certify potential trachoma graders. We trained 18 potential graders in the WHO simplified grading system for a trachoma study in Ethiopia, and all 18 took the certification examination. Trainees varied in their prior field experience. 4 trainees were novices, 4 had participated in 1 study-visit, 1 had participated in 2 study-visits, 3 had participated in 3 study-visits, 1 had participated in 4 study-visits, and 5 trainees had participated in 6+ study-visits.unanimous. Borderline or marginal cases are defined as those photos in the testing set where the three experienced graders did not unanimously agree on presence or absence of clinical activity. Kappa statistics on TF grades and, separately, TI grades, were calculated for each of the 18 trainees on the full set of 200 photographs by comparing the trainee's grade with the consensus grade. Kappa statistics were then recalculated on the unanimous subset of cases only. Bootstrap 95% confidence intervals were determined by resampling trainees (n = 999).In addition to the 18 trainees, three experienced graders  graded each of the 200 cases as either having TF or no TF and as having TI or no TI. Each was masked to the others' grades. A consensus grade was defined for each case as the one that at least 2 of the 3 experienced graders agreed upon. Cases for which all three experienced graders were in agreement were sub-classified as N = 200 cases into K = 4 mutually exclusive bins, representing forecast probabilities. Cases that the three experienced graders unanimously agreed were not TF were placed into the “0/3 TF activity” bin. Cases which one, two, or three experienced graders called as TF, were placed into the “1/3 TF activity”, “2/3 TF activity”, and “3/3 TF activity” bin, respectively. kn is the number of cases in the bin, kf is the forecast probability for that bin  and n = 999). Calculations were repeated for the clinical grade of TI.Equation 1 K = 3 bins. Cases for which there was unanimous agreement amongst our 3 experienced graders as being not TF were put in the 0/2 TF activity bin. Cases for which there was unanimous agreement amongst experienced graders as TF were placed in the 2/2 TF activity bin. Cases which had any level of disagreement amongst experienced graders were placed in the 1/2 TF activity bin .To compare the effect of bin size, reliability error was recalculated for TF using Mathematica 9.0 .Linear regression was used to assess the relationships of these measures with each other. All calculations were performed in Out of 200 cases, the three experienced graders all agreed 76 were not TF (39% of cases) and 80 were TF (40%), giving unanimous agreement to 156 cases (79%) while disagreeing on 44 cases (21%). When assessing inter-grader agreement on the full set of 200 cases, the mean kappa score of the 18 trainees for TF was 0.774 (95% CI 0.746 to 0.800). Restricting the assessment to cases for which there was unanimous agreement amongst the 3 experienced graders (156 out of 200 cases), the mean kappa increased to 0.896 (95% CI 0.861 to 0.926). The difference in mean kappa scores was 0.122 (95% CI 0.108 to 0.136) higher when restricting analysis to the unanimous subset of cases.With TI grading of the full set of 200 cases, the three experienced graders all agreed 98 were not TI (49% of cases) and 51 were TI (25.5%), giving unanimous agreement to 149 cases (74.5%) and disagreeing on 51 cases (25.5%). Mean kappa across 18 trainees for TI was 0.707 (95% CI 0.671 to 0.744) on the full set of 200 cases. Restricting analysis to the unanimous subset (149 out of 200 cases), the trainees' mean kappa for TI increased to 0.795 (95% CI 0.756 to 0.833). The difference in mean kappa scores was 0.088 (95% CI 0.070 to 0.107) higher for the unanimous subset.Reliability error and Brier score for TF were calculated for the 18 trainees using the 200 cases placed into 4 bins. The three experienced graders unanimously agreed 78 cases were not TF (0/3 TF activity bin) and 80 cases were TF (3/3 TF activity bin). There were 18 cases which were called TF by only 1 experienced grader (1/3 TF activity bin) and 26 cases which were called TF by 2 experienced graders (2/3 TF activity bin). Mean reliability error for the 18 trainees on the full set of cases was 0.013 (95% CI 0.007 to 0.021). Mean reliability error for the unanimous subset (i.e. the 156 cases in the 0/3 TF activity and 3/3 TF activity bins) was 0.009 (95% CI 0.004 to 0.018). The difference in mean reliability error was 0.004 (95% CI 0.001 to 0.006) higher for the full set as compared to the unanimous subset. Mean Brier score for TF on the full set of cases was 0.089 (95% CI 0.078 to 0.101). Mean Brier Score the unanimous subset (i.e. 2 bins) was 0.052 (95% CI 0.038 to 0.069). The mean Brier score was 0.037 (95% CI 0.033 to 0.040) higher on the full set of cases for TF grading.Reliability error and Brier score for TI were calculated for the 18 trainees using the full 200 cases placed into 4 bins. The three experienced graders unanimously agreed 98 cases were not TI (0/3 TI bin) and 51 cases were TI (3/3 TI bin). There were 40 cases which were called TI by only 1 experienced grader (1/3 TI bin) and 11 cases which were called TI by 2 experienced graders (2/3 TI bin). Mean reliability error for TI on the full set of cases was 0.034 (95% CI 0.025 to 0.045). Mean reliability error on just the unanimous subset (i.e. 2 bins) was 0.025 (95% CI 0.018 to 0.035). The difference in mean reliability error was 0.009 (95% CI 0.005 0.013) higher for the full set. Mean Brier score on the full set of cases was 0.110 (95% CI 0.098 to 0.122). Mean Brier Score for the unanimous subset (i.e. the 0/3 and 3/3 bins) was 0.087 (95% CI 0.070 to 0.104). The mean difference in Brier score was 0.023 (95% CI 0.019 to 0.029) higher on the full set of cases for TI.The mean proportion of cases the 18 trainees scored as TF in the 0/3 TF activity bin, which contained the 76 cases that all three experienced graders scored as normal, was 6.9% (95% CI 3.9% to 10.5%). Mean proportion of cases called TF in the 1/3 TF activity bin, containing the 18 cases which only 1 experienced grader called TF, was 50.9% (95% CI 43.8% to 57.7%). Mean proportion of cases scored as TF in the 2/3 TF activity bin, containing the 26 cases that 2 experienced graders called TF, was 80.1% (95% CI 75.0% to 85.7%). Mean proportion of cases called TF in the 3/3 bin, containing the 80 cases all experienced graders called TF, was 96.5% (95% CI 95.7% to 97.4%).Similarly for TI, the mean proportion of cases the 18 trainees scored as TI in the 0/3 TI bin, which contained the 98 cases that all three experienced graders scored as normal, was 0.6% (95% CI 0.06% to 1.24%). Mean proportion of cases called TI in the 1/3 TI bin, containing the 40 cases which only 1 experienced grader called TI, was 11.8% (95% CI 6.3% to 17.8%). Mean proportion of cases scored as TI in the 2/3 TI bin, containing the 11 cases that 2 experienced graders called TI, was 46.5% (95% CI 37.4% to 55.1%). Mean proportion of cases called TI in the 3/3 bin, containing the 51 cases all experienced graders called TI, 75.8% (95% CI 71.5% to 80.3%).As an example, we report kappa scores and reliability errors for TF for 2 individual graders. Grader A had a kappa of 0.736 and a reliability error of 0.033. %TF in the 0/3 TF, 1/3 TF, 2/3 TF and 3/3 TF activity bins were 14.5%, 72.2%, 96.1%, and 98.8%, respectively. Grader B had a kappa of 0.739 and a reliability error of 0.005. %TF in the 0/3 TF, 1/3 TF, 2/3 TF and 3/3 TF activity bins were 5.3%, 50%, 57.7%, and 97.5% respectively. Thus trainees with similar kappas may have different reliability scores.Reliability error for TF grades was recalculated by categorizing the 200 cases into 3 bins, instead of 4, by merging the 1/3 and 2/3 TF activity bins into a single 1/2 TF activity bin. The three experienced graders unanimously agreed 76 cases were not TF (0/2 TF bin) and 80 cases were TF (2/2 TF bin). There were 44 cases which the experienced graders disagreed on (1/2 TF bin). Mean reliability error for TF on the full set of cases in 3 bins was 0.008 (95% CI 0.004 to 0.014). Mean reliability error on just the unanimous subset (i.e. 2 bins) was 0.009 (95% CI 0.004 to 0.018). The difference in mean reliability error across all 18 trainees between the full set of cases  and the unanimous subset (2 bins: 0/2 and 2/2 TF activity) was 0.001 (95% CI −0.002 to 0.004). The mean proportion of cases the 18 trainees scored as TF in the 0/2 TF activity bin, which contained 76 cases that all three experienced graders scored as normal, was 6.9% (95% CI 3.9% to 10.5%). The mean proportion of cases called TF in the 1/2 TF activity bin, containing 44 cases which the three experienced graders disagreed on, was 68.2% (95% CI 62.9% to 73.1%). Mean proportion of cases called TF in the 2/2 bin, containing 80 cases all experienced graders called TF, was 96.5% (95% CI 95.7% to 97.4%).2R = 0.55) and a weak correlation for TI (2R = 0.36). Brier score and kappa are much more highly correlated, as 2R = 0.92 for TF and 2R = 0.94 for TI.As shown elsewhere with a different test set and trainees When the kappa statistic is used to compare a trainee's score with a gold-standard, it is essentially a scaled accuracy, with the relationship between kappa and accuracy perfectly linear when the prevalence of disease is 50%, and close to linear otherwise. Kappa requires marginal cases be classified as either having clinical activity or not. In contrast, reliability error treats cases as having a probability of possessing activity, which here we set equal to the proportion of 3 experienced graders scoring that case active. Reliability error assesses how close the proportion of positive observed outcomes, given a forecast probability, are to that forecast probability. For a trainee to have perfect (ie 0) reliability error on the 200 cases in this study, he/she must grade no cases in the 0/3 TF activity bin as TF (0 out of 76 cases), one-third in the 1/3 TF activity bin (6 out of 18 cases), two-thirds in the 2/3 TF activity bin (approximately 17 out of 26 cases), and all in the 3/3 TF activity bin (80 out of 80 cases). In contrast to kappa and accuracy, reliability error does not assess the individual grades a trainee gives for borderline cases in the 1/3 and 2/3 TF activity bins; rather, it assesses the proportion of cases scored active in those bins overall.2R = 0.56 for TF and 2R = 0.36 for TI).Brier score is highly correlated to kappa , and thuIn contrast to kappa, reliability error can be constructive. We expect the proportion of TF or TI called in the 0/3, 1/3, 2/3 and 3/3 activity bins to be 0%, ∼33%, ∼66%, and 100% respectively. We found for TF, mean activity  in those bins to be 6.9%, 50.9%, 80.1%, and 96.5%, respectively. For TI, the mean activity was 0.6%, 11.8%, 46.5%, and 75.8%. Thus, there was a tendency for our trainees to over-call TF and under-call TI, especially marginal cases (1/3 and 2/3 activity TF and TI bins). The proportion of activity called in each bin could be used, at the level of the trainee, to specifically refine scoring over portions of the disease spectrum, making reliability error a constructive measure. For example, two graders had nearly identical kappas (0.736 and 0.739), but reliability errors nearly 7-fold different (0.033 vs 0.005). One grader clearly over-called obviously normal cases (0/3 TF bin) as well as moderate cases of TF (1/3 and 2/3 TF bin). We used this information to remediate the grader's tendency to over-call clinical activity.Furthermore, in contrast to kappa scores, reliability error scores are not necessarily subject to reduction by inclusion of borderline cases. Though we see a statistically significant difference in mean 4-binned reliability error between the full set of cases and the unanimous subset for both TF and TI, our trainees disproportionately over-called TF and under-called TI grades for borderline cases (the 1/3 and 2/3 activity bins). In our re-calculation with 3 bins for TF, there was no statistically significant difference in mean reliability error scores between the full set of cases and the unanimous subset. Though trainees tended to over-call TF in this recalculation, the borderline cases (1/2 TF activity bin) were not disproportionately over-called. Further studies must be done to determine an optimal number of bins to use when calculating reliability error for trachoma grades.Our study has limitations which may affect generalizability. We only analyzed cases from a specific hyper-endemic region in Niger. Other countries may have a different spectrum of disease. We had 3 experienced graders score the 200 cases; there may be variability among other experienced graders on these 200 cases. Additionally, using a larger number of experienced graders may allow for better resolution in categorizing cases as marginal. We used 4 bins to categorize cases, based on the proportion of the three graders that scored the case as having activity. A different binning procedure can demonstrate different results, as discussed previously in the 3-bin recalculation. Conjunctival photographs were used to train graders and perform this study. Field examination has several advantages over photo grading, including that the conjunctiva may be examined from multiple angles, is always in focus, and illumination can be adjusted. The conjunctiva is a three-dimensional structure, particularly when inflamed, whereas a photograph is a two-dimensional representation Because of its relatively low cost, trachoma control programs will likely continue using clinical examination to make treatment decisions. Thus proper training of field graders is important. To ensure high-quality grading, these graders should be trained on the full spectrum of disease that they are likely to encounter in the field. Using the kappa statistic to judge certification can be difficult to interpret, depending on how widely experienced graders disagree on cases in the test set, given that inclusion of marginal cases tends to deflate apparent agreement. If even experts disagree, a trainee's answer may reveal little and lower their inter-grader agreement, as assessed by a kappa statistic. However, information can be learned about how a grader is assessing marginal cases by looking at the breakdown of their reliability error. Further studies can help determine if reliability error would also be an important metric to certify graders.


Ankylosing spondylitis (AS) is a chronic destructive and inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine.The aim of the present cross-sectional study was to evaluate and identify factors leading to delayed diagnosis of AS in Iranian patients.Sixty patients,  with a diagnosis of AS according to the modified New York criteria were recruited. Diagnosis delay was defined as the interval between a patient’s first spondyloarthritic symptoms  and a correct diagnosis of AS.The average age of patients at diagnosis of AS was 36.4 ± 4.5 years and the average of delay in diagnosis was 6.2 ± 3.5 years. The most common diagnosis at the first visit was disc herniation (68.3%). Delay in diagnosis of Human Leukocyte Antigen (HLA-B27) positive and negative patients were 4.6 ± 2.2 years and 10.1 ± 3.2 years, respectively (P = 0.0001). Diagnosis delay in patients with morning stiffness and IBP were significantly shorter than that of patients without these symptoms . Patients with uveitis had the shortest diagnosis delay (P = 0.02). The Bath Ankylosing spondylitis disease activity index (BASDAI) was not significantly different in early (< 3years) and late (> 3years) diagnosis  (P = 0.18), but the Both ankylosing spondylitis functional index (BASFI) was significantly different between them (3.3 ± 1.0 and 4.1 ± 0.7 respectively) (P = 0.001).In this study, delay in diagnosis was similar to other studies. Educating physicians to careful history taking especially in the case of IBP, non-musculoskeletal symptoms such as uveitis and precise physical examination are important in early diagnosis. Ankylosing spondylitis (AS) is characterized by inflammation and new bone formation in axial skeleton and enthesis. Peripheral joints and other organs such as skin, eye and heart may be involved. The prevalence of AS closely parallels the frequency of Human Leukocyte Antigen HLA-B27) and varies from 0.1% to 1.2% in different populations 7 and var. AS is mThe aim of the present cross-sectional study was to evaluate and identify factors leading to delay in the diagnosis of AS in Iranian patients.This was a cross sectional study performed in Emam Reza Hospital-Tabriz, Iran. The ethics committee of Tabriz University of Medical Sciences reviewed and approved the present study, which complies with the Declaration of Helsinki. Informed consent was obtained from all the participants in the study. Sixty patients  were selected in university rheumatology clinics, Tabriz- Iran. The Modified New York criteria was used to diagnosis AS. All patients previously diagnosed as AS were rechecked and confirmed by two rheumatologists .morning stiffness of > 30 minutesimprovement in back pain with exercise but not with restawakening because of back pain during the second half of the night only and alternating buttock pain .We assumed 6 mg/L as the cut of level for CRP based on the recommendation of manufacturer kits. Regarding patients' age and gender, we chose 30 mm/h for ESR level. Presence of AS  in the first or second-degree family of patients confirmed by rheumatologist was considered as positive family history. All patients were examined precisely by a rheumatologist. Disease activity was assessed by using the Bath ankylosing spondylitis disease activity index (BASDAI) , inflammatory arthritis, enthesopathy and uveitis] and a correct diagnosis of AS. Criteria for inflammatory back pain were:(BASDAI) , and fun(BASDAI) .In all patients, radiography of sacroiliac joints and lumbar spine were taken. Peripheral joints radiography in the case of their involvement was also performed. Grading sacroiliitis, was according to the New York criteria  All radiographies were reported by a radiologist. Erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and human leukocyte antigen B27 (HLA-B27) were determined. All data were entered the SPSS software package version 13 for Windows  for statistical analysis. Results were expressed as mean ± SD, numbers, and percent when appropriate. The Student’s t test was used for statistical analyses and P < 0.05 was considered significantDemographic characteristics of the patients are shown in The average number of physicians who visited patients before the correct diagnosis was 4.1. Only four patients, one by a neurosurgeon and three by rheumatologists were correctly diagnosed at the first visit. The diagnoses at the first visit were disk herniation (68.3%), Ankylosing Spondylitis (6.6%), osteoarthritis (5%), sprain (5%), psychogenic pain (5%) and heel spur (3.3%). The correct diagnosis by Rheumatologists was higher than that of others (83.3%). The percentage of correct diagnosis was 5% by neurosurgeons and 11.7% by Internists, rehabilitationist, neurologists and general physicians. The average of diagnosis delay according to the manifestations of disease is shown in In this study diagnosis delay was not sex dependent (P = 0.14). When patients had heel pain, diagnosis delay was very long (13 ± 0.0 years). The shortest (2.4 ± 0.3 years) delay was when patients had anterior uveitis. The average of diagnosis delay according to some laboratory data is shown in According to diagnosis delay we divided patients into two groups: early diagnosis < 3 years and late diagnosis > 3 years. BASDAI in early diagnosis was 3.3 ± 0.9 years and in late diagnosis was 3.6 ± 0.7 years and there were no significant differences between them (P = 0.18). On the other hand, BASFI were 3.3 ± 1.0 and 4.1 ± 0.7 on early and late diagnosis respectively with significant differences (P = 0.001). Radiographic findings in our patients were: Sacroiliitis , squaring (18.33), Romanus lesion (6.6%), Bamboo spine (6.6%) and enthesopathy (6.6%) .Ankylosing spondylitis (AS) is a chronic destructive and inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine. Early diagnosis is important, because new drugs such as antitumor necrosis factor (TNF) agents are effective on reducing disease progression, enthesitis, spinal mobility and arthritis -20. For AS diagnosis at an early stage depends primarily on a careful history taking and physical examination. Inflammatory back pain is an important clinical symptom of AS and there are no costs to evaluate this feature. Inflammatory back pain can be diagnosed with a sensitivity of 95% and specificity of 85 to 90% . Braun eThe first common symptom presented in our study was inflammatory lumbar pain (51.7%) and the common diagnosis at first visit was disc herniation (63%). Unfortunately, it emphasizes that physicians are not careful about IBP. Only 16.7% of our patients were correctly diagnosed by non-rheumatologist physicians. On the other hand we must know that 20-30% of AS patients may also present with mechanical back pain . In thisIn our study the average diagnosis delay was 4.6 ± 2.2 years and 10.1 + 3.2 years in HLA-B27 + and HLA-B27–patients respectively (P = 0.0001). HLA-B27 is not a criterion for the diagnosis of AS patients in the modified New York criteria, but used in the ASAS criteria. It seems that when physicians visit HLA-B27 positive patients, they mostly think of AS. In Feldtkeller et al. study, the average diagnosis delay were 11.4 and 8.5 years, in HLA-B27 negative and HLA-B27 positive patients respectively .Sonkar study showed that frequency of HLA- B 27 positivity is high in SSA (Seronegative Spondyloarthropathies) in childhood and in young adult males. Sonkar et al. study showed that HLA- B27 positive patients have more severe disease and systemic manifestation . Our resA significant association was found between elevated ESR and shorter diagnosis delay. It may reflect that when physicians visit a patient with elevated ESR they are more sensitive to investigated inflammatory diseases such as AS. Based on early (< 3 years) or late (> 3 years) diagnosis delay, there were no significant differences in BASDAI score (P = 0.18), but in BASFI it was very significant (P = 0.001). Because many of our patients were diagnosed after several years, at the time of their disease was not very active based on BASDI but it was suspected functional status of patients decreased during disease progression. Ineffective treatment may be another cause of no differences in BASDI for early or late diagnosis. When we compared BASDAI and BASFI in the two groups (receiving Anti-TNF and or not) of patients, we found significant differences between them . AS patients with shorter duration of disease are more likely to respond to anti-TNF agents than those with long-standing disease .In this study, all the patients at the diagnosis had sacroiliitis at radiography but we could not establish when radiographic changes occurred. In the modified New York criteria, sacroiliitis is essential for diagnosis. However, in many patients with AS, it may take years from the onset of AS symptoms to appear. It must be emphasized that if there was IBP in the early period of AS, absence of sacroiliitis should not be considered to rule out diagnosis . In patiFamily history of spondyloarthritis is a key element in the evaluation of patients for AS. A family history of AS can be found in 15% to 20% of cases . In our Educating physicians to take careful history especially about IBP, attention to non-musculoskeletal symptoms such as uveitis, arthritis, enthesopathy, precise physical examination and HLA-B27 are important in early and definite diagnosis of AS. Patients with arthritis and enthesopathy should be referred to rheumatologists since the patients had longest diagnosis delay. However, our findings are limited by the small number of patients included and we need to perform further studies with a greater number of patients .


Clobazam is used for the treatment of different types of seizure and epilepsy. The present research is undertaken to study the systematic forced degradation of clobazam and to identify its main degradation product under basic conditions.2PO4 50 mM (pH 8.5) and acetonitrile  as the mobile phase with UV detection at 230 nm.The degradation of clobazam was studied under different conditions. Clobazam and its degradation products were separated using a Nova-Pak C18 column and a mixture of KH2O2. Using the tablet powder, higher degradation rates were observed under different stress conditions. The main degradation product of clobazam under basic condition was subsequently characterized.The within-day and between-day precision values in the calibration range of 0.1-20 μg/ml were within 0.5-1.5%. Clobazam was relatively stable in solid from under exposure to visible and UV light and also heat. The clobazam aqueous solution of clobazam was more labile under exposure to visible and UV light. The bulk drug was significantly degraded under exposure to 2 M HCl, 0.1 M NaOH or 3% HThe developed method could be used for the determination of clobazam in the presence of its degradation products with acceptable precision and accuracy. The applicability of the proposed method was evaluated in commercial dosage forms analysis. Clobazam bulk powder is a white crystal with molecular weight of 300.7. The drug is slightly soluble in water and soluble in alcoholic solvents. A number of HPLC methods have been reported before for the determination of clobazam and its metabolite in human plasma -N-methylacetamide : δ (ppm); 1.93 , 3.23 , 6.84 , 7.03 , 7.10-7.17 , 7.25 , 7.34-7.41 .Mass: m/z (%) 276 (7), 274 (21), 259 (33), 257 (100), 231 (15), 215 (18), 195 (13), 181 (7), 167 (8), 153 (7), 91 (7) , 1644 (CO).IR (KBr): ν cmThe active ingredient in clobazam tablets (10 mg) was determined using the developed method. Good agreement with the label claimed amount (10.29 ± 0.11 mg per tablet) was observed with no interference from excipeients.In this study clobazam was exposed to different stress conditions recommended in ICH guidelines. In the developed HPLC method, clobazam and its degradation products were resolved in a single isocratic run. Clobazam showed significant degradation under basic, acidic or oxidative conditions. The bulk drug remained unaffected under heat, UV light or visible light in the solid form, while significant degradation in these conditions was observed in aqueous solutions. The tablet powder was more labile under studied degradation conditions. The main degradation product under 0.1 M NaOH was separated and its chemical structure was elucidated. The proposed analytical method was relatively simple and accurate and could be used for the determination of clobazam in pharmaceutical dosage forms in the presence of its degradation products.The authors declare that there is no competing interests.ES has supervised the project and prepared the article. ADE has done the experimental part of the project. RA has performed the peak purity tests and obtained the mass spectrum. MA has performed the characterization of the degradation product. All authors read and approved the final manuscript.


Nidation of floating tumour cells initiates peritoneal carcinosis and limits prognosis of gastro-intestinal tumours. Adhesion of tumour cells to extracellular matrix components is a pivotal step in developing peritoneal dissemination of intraabdominal malignancies. Since phospholipids efficaciously prevented peritoneal adhesion formation in numerous animal studies we investigated their capacity to reduce adhesions of gastric cancer cells to extracellular matrix components (ECM).Human gastric cancer cells  were used in this study. Microtiter plates were coated with collagen IV (coll), laminin (ln) and fibronectin (fn). Non-specific protein binding of the coated wells was blocked by adding 1% (w/v) BSA  and rinsing the wells with Hepes buffer. 50.000 tumour cells in 100 μl medium were seeded into each well. Beside the controls, phospholipids were added in concentrations of 0.05, 0.1, 0.5, 0.75 and 1.0/100 μl medium. After an incubation interval of 30 min, attached cells were fixed and stained with 0.1% (w/v) crystal violet. The dye was resuspended with 50 μl of 0.2% (v/v) Triton X-100 per well and colour yields were then measured by an ELISA reader at 590 nm. Optical density (OD) showed a linear relationship to the amount of cells and was corrected for dying of BSA/polystyrene without cells.The attachment of gastric cancer cells to collagen IV, laminin, and fibronectin could be significantly reduced up to 53% by phospholipid concentrations of 0.5 mg/100 μl and higher.These results, within the scope of additional experimental studies on mice and rats which showed a significant reduction of peritoneal carcinosis, demonstrated the capacity of phospholipids in controlling abdominal nidation of tumour cells to ECM components. Lipid emulsions may be a beneficial adjunct in surgery of gastrointestinal malignancies. In the treatment of gastro-intestinal cancer the detection of free, isolated tumour cells in the peritoneal cavity serve as a prognostic marker for postoperative survival -4. Sincein vitro study was focused on the influence of phospholipids on adhesion of gastric cancer cells to extracellular matrix components with broad reactivity to several integrins. Collagen IV (coll IV), and laminin (ln) are main components of the basement membrane and fibronectin (fn) plays an important role in wound healing [Phospholipids, polar phosphoric acid di-esters, are natural constituents of the abdominal fluid. The substance is able to form a lubricant layer on the peritoneal surface . Additio healing ,18.2, Falcon, Becton Dickinson-Gambil, Heidelberg, Germany) in RPMI 1640 medium , supplemented with 10% foetal bovine serum (GIBCO), penicillin and streptomycin (GIBCO). Cell cultures were incubated at 37°C in a humidified atmosphere of 5% CO2 in air. Cells were passaged after treatment with 0.125% trypsin for 6 min. The cells were pelleted after centrifugation for 10 min at 200 g, suspended in 20 ml PBS, and pelleted. The cell pellet was resuspended in 30 ml complete medium and seeded with a splitting ratio of 1:3. Only cells from three passages were used for the experiments.The human gastric cancer cell line NUGC-4 was purchased from the Japanese Cancer Research Resources Bank . The cells were maintained in monolayers in tissue culture flasks (75 cm2 in air (ln), respectively. Nonspecific protein binding of the coated wells was blocked by adding 1% (w/v) BSA  and rinsing the wells with Hepes buffer.Flat-bottom polystyrene microtiter plates  were coated for adhesion experiments. The purified ECM components were dissolved in PBS with the following concentrations: coll IV – 2,5 μg/ml , fn – 10 μg/ml , ln – 50 μg/ml . We found these concentrations to be optimal in foregoing dilution series. They were added to the wells and incubated at 4°C for 24 hours , or at 37°C for 45 min in a humidified atmosphere of 5% CO3 and 5 × 104 cells per well, as determined by a dilution series.For adhesion experiments gastric cancer cells were detached with collagenase I , washed once with RPMI 1640, centrifuged (200 g for 10 min), resuspended in RPMI 1640, and preincubated for 30 min in a humidified atmosphere of 5% CO2 in air (37°C). Fifty thousand tumour cells in 100 μl medium were seeded into each well. Evaluation of adherent cells was performed using crystal violet staining according to the method described by Aumeilley et al., and Tietze et al. ,20. AfteControl dying of BSA/polystyrene without cells led to Optical Density (OD) values of 0.01–0.07. These values were subtracted from those obtained in the experiments.After complete preparation of the tumour cell suspension, the PL solution was added in the following concentrations: 0.05, 0.1, 0.5, 0.75, and 1 mg per 100 μl medium. The concentrations used were correlated to our in vivo experiments. The phospholipid solution consists of phosphatidylcholine 70% by weight, phosphatidylethanolamine 15% by weight, neutral lipids 8% by weight, sphingomyelin <3% by weight and lysophosphatidylcholine <3% by weight.All experiments were performed three times in quadruplicate. The data are expressed as means +/- standard error of the mean (SEM). Student's t-test for unpaired data was used for statistical analysis. Differences were regarded as significant for p values < 0.05.The analysis of tumour cell adhesion to BSA 1% resulted in a mean extinction of 0.27 (SEM 0.01) at 590 nm. Coating with ln and fn led to a nearly twofold increase of tumour cell adhesion with mean values of 0.59  and 0.63 . The cancer cells showed a most pronounced adhesion to coll IV with a mean extinction of 0.97 (0.02).The tumour cell adhesion to ln registered after addition of PL was significantly reduced. The effect was concentration dependent compared to the controls. Even the minimum amount of PL 0.05 mg/100 μl led to a reduced extinction of 0.4 (0.01). Treatment with 0.1 or 0.5 mg/100 μl PL revealed extinction values of 0.32 (0.02) and 0.28 (0.02), respectively. The maximum effect could be demonstrated with 0.75 mg/100 μl PL with an extinction of 0.24 (0.02). The relative reduction of tumour cell adhesion compared to the control amounts to 59%. Treatment with 1 mg/100 μl PL showed no further decrease of tumour cell adhesion to ln. The mean extinction was 0.26 (0.01)  and 0.59 (0.01). However, a significant reduction of tumour cell adhesion could be observed after treatment with 0.5 mg/100 μl PL, 0.42 (0.02); as well as with 0.75 mg/100 μl PL (0.39 (0.02)) and 1 mg/100 μl PL (0.38 (0.02)). We found a similar situation compared to ln with equal effects of 0.75 mg/100 μl and 1 mg/100 μl PL indicating that the maximum influence on adhesion is reached. The relative reduction of tumour cell adhesion compared to the control values amounts to 40%  after administration of 0.05 mg/100 μl PL to a maximum effect after treatment with 1 mg/100 μl PL with a value of 0.44 (0.02) table . In compCell adhesion to the extracellular matrix plays a fundamental role in peritoneal carcinosis. The adhesion is mediated by transmembrane Integrins. Several proteins including fibronectin in the interstitial matrix, laminin and collagen IV in the basement membrane were identified as important ligands ,22. Manyin vitro as well as a reduction of tumour weight after intraperitoneal tumour injection [In our experiments the reduced rate of cell attachment in the presence of phospholipids was independent from the extracellular matrix. A similar effect on intraperitoneal tumour growth was described by Jacobi et al. who could demonstrate that taurolidine/heparin and povidone iodine lead to a significant reduction of tumour cell growth njection . Predominjection . Dextrannjection ,32. Howenjection ,34. PhosThe hypothesis is that phospholipids form a lubricant layer on the peritoneum by binding with its negatively charged cholin branch chain to the positively charged peritoneal surface ,14,35. Pin vitro experiments with tumour cells as soluble agents added to ECM immobilized onto plastic surfaces cannot appropriately mimic the situation in situ. Recently we found that phospholipids significantly reduce the attachment area and the tumour volume of peritoneal carcinosis caused by the colonic cancer cell line DHD/K12/TRb in rats. These results were supported by a prolonged survival rate of the treated animals as compared to the control group. Additionally, we found a similar effect of phospholipids on the adhesion of the human rectal cancer cell line HRT-18 on the same ECM-components in vitro [The in situ tumour cell – ECM interaction is influenced by adhesive and non-adhesive ECM components and can be understood as a three dimensional network . Therefoin vitro . Consistin vitro ,6,38,39.We performed this study to ascertain the results of the foregoing animal experiments and to demonstrate the influence of phospholipids to three different ECM components, even though matrices of collagen IV, laminin and fibronectin alone may not be predictive of peritoneal membrane nidation.These results, within the scope of additional experimental studies on mice and rats which showed a significant reduction of peritoneal carcinosis, demonstrated the capacity of phospholipids in controlling abdominal nidation of tumor cells to ECM components. Lipid emulsions may be a beneficial adjunct in surgery of gastrointestinal malignancies.The work was financially supported by Fresenius Kabi, Bad Homburg, Germany.The results are part of an international patent application.The pre-publication history for this paper can be accessed here: