Salmonella enteritidis causes infections in humans and animals. Antibiotics are used to eliminate bacterial infections, which become resistant to antibiotics after a while. This study aimed to isolate S. enteritidis from cattle feces samples and also to evaluate the frequency of genes associated with multi-drug resistance (MDR).S. enteritidis. Disk diffusion method was used to assess antibiotic susceptibility. Then Polymerase chain reaction (PCR), assay was used for definitive diagnosis of S. enteritidis and resistance genes.One hundred ten fecal samples of cattle were collected from Jul to Dec, 2017 in Khuzestan Province, southern Iran. Bacterial culture and molecular methods were used to isolate and identify Salmonella genus and 86 samples (85.14%) were identified as S. enteritidis. The highest and lowest antibiotic resistance were belonged to gentamicin , and tetracycline . Besides, 64 samples (74.42%) had 2–10 drugs resistance patterns. Moreover, the highest and the least resistance were related to IMP-1bla  and tet(B)  genes respectively.Overall, 101 (91.81%) samples were detected to be contaminated with S. enteritidis have a high frequency. Therefore, antibiotic resistance and high MDR to antibiotics can be due to the incorrect use of antibiotics and the lack of health monitoring in Cattle farms.The drug-induced genes in  Salmonella is one of the most important members of the Enterobacteriaceae family. This bacterium is a facultative intercellular, gram-negative, rod-shaped, bacilli-shaped, spore-free, aerobic and anaerobic pathogen  is among the most important disease-causing serotypes. So far, more than 2,500 Salmonella serovars have been identified based on flagellar and somatic antigens, most of which are pathogenic to humans and animals . Black and gray colonies were considered as suspected Salmonella. Complementary assays and differential microbial tests  and culturing on Triple Sugar Iron Agar (TSI) according to Bergey’s manual were used to detect Salmonella strain. The lysine decarboxylation was performed on isolated bacteria by culturing in lysine decarboxylase broth to identify the Salmonella family. Sulfide Indole Motility medium (SIM) was used for direct detection of Salmonella spp. by sulfide production, indole formation, and motility.The feces samples were transferred to concentrated peptone water and incubated at 37 °C for 24 h. Then, the samples were transferred to Rappaport Vassiliadis (RV) and incubated again at 43 °C for 24 h. The isolated bacteria were cultured on 16S rRNA gene was performed for the direct detection of Salmonella family. In the next step, Salmonella-encoded fimbria (sefA) gene was targeted for specific detection of S. enteritidis from other Salmonella strains. The primer sequences used in the present study are shown in 2, 5 μL of 10X PCR buffer AMS, 200 μM dNTPs, and 1 unit of Taq DNA polymerase . The PCR assay was performed at 95 °C for 5 min and then for 32 cycles of 94 °C for 1 min, annealing temp according to Genomic DNA was extracted using QIAamp mini kit . PCR method using specific oligonucleotide primers for S. enteritidis samples from other Salmonella strains. Then, the colonies were sub-cultured into Nutrient Broth  and incubated at 37 °C in a shaking incubator for 14 h. McFarland 0.5 turbidity standards were used for bacterial turbidity. After standardization, 100 μL of bacterial suspensions were cultured on Mueller-Hinton agar medium . Drug resistance testing was performed using standard Bauer-Kirby disk diffusion method for all samples (positive culture) according to CLSI protocols for determination of antibiotic susceptibility patterns of S. enteritidis isolated from feces specimens and the cultures were incubated at 37 °C for 24 h. The antibiotic disks were used for determination of antibiotic susceptibility patterns of S. enteritidis isolated from feces specimens.The colonies were cultured on Nutrient Agar  at 37 °C for 24 h after detection of positive S. enteritidis and the sequences of primers are available in 2, 5 μL of 10X PCR buffer AMS, 200 μM dNTPs, and 1 unit of Taq DNA polymerase . Reactions were initiated at 95 °C for 5 min, followed by 32 cycles of 94 °C for 1 min, annealing temp according to The PCR was performed for identification of resistance genes. The primers were blasted at the NCBI using the experimental GENINFO BLAST Network Service to assess degree of homology between these primers and other reported sequences and at the end were obtained from CinnaClon Co, Iran. The specific oligonucleotide primers for gene amplification of antimicrobial resistance genes in isolated P-value <0.05 was considered statistically significant.All statistical tests were performed using Graph Pad Prism statistical software, ver. 7.00 . For all tests, Salmonella by detecting 258 bp band of 16S rRNA gene. Furthermore, the numbers of 86 (85.14%) specimen were sefA gene positive (488 bp).Out of 110 samples, 101 (91.81%) samples were positive for The highest antibiotic resistance was observed to gentamicin  and the lowest antibiotic resistance was observed in tetracycline . Moreover, while the lowest antibiotic susceptibility belonged to sulfamethoxazole  . AccordiIMP-1bla genes  and the lowest resistance, on the other hand, was for tet(B)  gene. Detection of resistance genes in isolated S. enteritidis using PCR technique revealed fragments with specific length sizes in In the studied samples, the highest resistance belonged to the Salmonella genus and S. enteritidis respectively. IMP-1bla (84.88%) and tet(B) (56.97%) genes indicated the highest and the lowest frequency in comparison to other studied genes. However, the highest and lowest antibiotic resistances belonged to gentamicin (81.39%), and tetracycline (6.97%) antibiotics.The results of present study revealed that 91.81% and 85.14% were detected for S. enteritidis (43%) was reported in comparison with S. typhimurium. In contrast, a low Salmonella (1.6%) prevalence was reported in Italy  was relatively high. The highest resistance belonged to ampicillin (95.7%), kanamycin (93.6%), spectinomycin (93.6%), streptomycin (91.5%) and sulfamethoxazole (91.5%) (sul1 (76.6%), cat1 (43.3%), tetA (40%) and aadA1 (36.7%) genes (P<0.001).In Iran, a high prevalence of in Italy –18. The ritidis 4% was rep (91.5%) . In comp%) genes . Randall%) genes . In our The phenomenon of antimicrobial resistance has been an urgent global problem since the 1990s . The excS. enteritidis and the MDR. They identified 77.7% prevalence of S. enteritidis, 81% drug resistance, and 69% two or more resistances. The highest resistance phenotypes were streptomycin (58.3%), ampicillin (21.4%), sulfamethoxazole (17.85%), kanamycin (14.28%) and chloramphenicol (14.2%)  . HoweverSalmonella is different based on geographical zones. This study determined the widely spread prevalence of S. enteritidis and MDR in cattle from Khuzestan Province. Efforts that include further implementation of hazard analysis of critical control in livestock production are needed to reduce the incidence of Salmonella.The comparison of the results of present study with others suggests that both the prevalence and the antimicrobial resistance pattern for Ethical issues  have been completely observed by the authors.


Bacillus velezensis BY6 was isolated from the wood stems of healthy Populus davidiana × P. alba var. pyramidalis (PdPap). The BY6 strain can inhibit pathogenic fungus Alternaria alternate in PdPap and promote growth of PdPap seedlings. In the present study, we used the Pacific Biosciences long-read sequencing platform, a single-molecule real-time (SMRT) technology for strain BY6, to perform complete genome sequencing. The genome size was 3,898,273 bp, the number of genes was 4,045, and the average GC content was 47.33%. A complete genome of strain BY6 contained 110 secondary metabolite gene clusters. Nine of the secondary metabolite gene clusters exhibited antifungal activity and promoted growth functions primarily involved in the synthesis of surfactin, bacteriocins, accumulated iron ions, and related antibiotics. Gene clusters provide genetic resources for biotechnology and genetic engineering, and enhance understanding of the relationship between microorganisms and plants.An endophytic bacterium  Populus davidiana × P. alba var. pyramidalis (PdPap) is the most commonly planted tree species in China. Its characteristics include rapid growth, resistance to drought, and tolerance to low temperatures. PdPap is a female clone; the catkin can fall off naturally, and it is a model species for studying woody plants  × 100.The antifungal activity of strain BY6 was tested with reference to the method by Chernin et al. . A 5 mm 8 CFU/mL). The treatment group was inoculated with 50 mL of bacterial cells per pot of PdPap by root irrigation, and the control group was inoculated with 50 mL of sterile water. PdPap seedlings were separated in advance using stem segments, and then transferred into the half-strength Murashige and Skoog (1/2 MS) macronutrient medium . PdPap seedlings were transplanted into a pot containing a mixture of black soil with a vermiculite ratio of 7 : 3 (v/v) after growing 3 to 5 leaves. The soil mixture used was autoclaved at 121°C for 2 hours before transplanting the seedlings. The seedlings were cultivated in a greenhouse with the following conditions: 25°C, 16 h light : 8 h dark photoperiod, and 40% humidity. The seedlings were watered on a weekly basis with 50 mL of sterile water throughout the growth period. Thirty days after inoculating PdPap seedlings with BY6 according to the method described by Sanchez-Hernandez [We inoculated the strain BY6 in LB culture medium, and the culture was shaken at 160 rpm at a temperature of 25°C for 5 days. Culture was centrifuged at 120,000 rpm for 5 min at 4°C to remove the supernatant, and the bacterial cells were subsequently diluted with sterile water (OD ≈ 1.8 × 10http://topaz.gatech.edu/GeneMark/). We compared the protein sequences of the predicted genes to the protein database of Clusters of Orthologous Groups (COGs) (http://www.ncbi.nlm.nih.gov/COG) and obtained the corresponding COG annotation results [https://www.genome.jp/kegg/), and then identified relevant pathways for corresponding genes [http://www.geneontology.org) was used to analyze BLAST results. The antiSMASH program (version 2.0.2) [We used the single-molecule real-time (SMRT) technology on the Pacific Biosciences sequencing platform to sequence the complete genome of strain BY6. The SMRT Link version 5.0.1 , 22 vari results . BLAST sng genes , 25. Genn 2.0.2)  was usedn 2.0.2)  to visuaB. velezensis (NR075005.2) and B. velezensis (NR116240.1) exhibiting the closest genetic distance to B. velezensis (NR116240.1), with a support rate of 97%. Strain BY6 was identified as B. velezensis based on our experimental results.Strain BY6 was isolated from the wood stems of healthy PdPap seedlings. After culturing BY6 on LB medium at 25°C for 3 days, the colonies were nearly spherical with uneven surfaces, wrinkled, milky white, and odorless . The GraA. alternata was tested. After 5 days of coculturing with A. alternata, a significant inhibition zone appeared . In addition, strain BY6 can adapt to extremely cold environments such as isolated areas in the Maoer Mountain . It can also withstand high temperatures of 90°C. Consequently, BY6 is a strain of bacteria that can be potentially used as a biocide for controlling plant diseases.The antifungal activity of strain BY6 against appeared , indicatP < 0.01). Dry weight, leaf length, and leaf width were significantly different between the treatment and control groups (P < 0.05). The results indicate that BY6 has a strong plant growth promotion effect. Therefore, BY6 is a strain that can be potentially used to develop microbial fertilizers to enhance plant growth.The growth-promoting effect of strain BY6 on PdPap seedlings was evaluated 30 days after inoculation with strain BY6. The overall growth of PdPap seedlings in the treatment group was significantly higher than that in the control group . VegetatThe complete genome for strain BY6 comprised a circular chromosome of 3,898,273 bp with 3,923 protein-coding genes, 27 rRNA genes, 9S rRNA genes, and 86 tRNA genes. The GC content of the chromosome was 47.33%, with 8 gene islands and 16 prophages . The comIn the complete genome sequence of BY6, 3,315 genes were annotated with COG function, accounting for 81.95% of the complete genome sequence. The identified proteins were divided into 25 categories based on their functions . The funA. alternata.We also established that 599 related genes were involved in the bacteriostasis and biosynthesis of secondary metabolites. Analysis of the secondary metabolites of BY6 revealed that there were 9 gene clusters with antibacterial properties . Gene clA comparison of the BY6 genome sequence with the other three complete genome sequences of this species, LPL-K103 , FZB42 , and QSTThe BY6 genome contains numerous genes that promote plant growth. We postulated that one secondary metabolic gene cluster produces ferredoxin, a strong iron carrier that increases absorption of iron ions from the soil. BY6 also contains a few other related genes that promote plant growth, including encoding butanone and polyketide among others. Furthermore, BY6 has genes responsible for nitrogen fixation. Therefore, the host plant can absorb these substances to complete its auxin biosynthesis process. Auxin biosynthesis is instrumental in the growth and development of the roots, stems, and leaves of PdPap.PdPap is one of the most widely planted tree species in China. Various fungal diseases of plant leaves are increasingly occurring with the continuous expansion of PdPap plantations and degradation of the environment, adversely affecting the growth of PdPap. In the present study, the bacterial strain BY6 was isolated from PdPap. Biologically controlled experiments were performed, and results demonstrated that the strain BY6 can inhibit the growth of mycelia of the leaf blight pathogen in PdPap and promote the growth of PdPap seedlings. The endophytic bacterial strain BY6 was isolated from healthy PdPap wood stems. A few studies have indicated that PGPB, which have coevolved with the host plants or are compatible with growth environments, are beneficial to plants. Moreover, PGPB will not cause substantial damage to the host plants, but it can establish a harmonious symbiotic relationship with the host plant .A. alternata. Bacilysin is one of the simplest peptide antibiotics secreted by certain species of Bacillus [Bacillus [Bacillus species, and their antibacterial activity has been widely reported [Bacillus amyloliquefaciens BAS23 that have antifungal activity and plant growth-promoting activity [B. velezensis.We sequenced the complete genome of bacterial strain BY6 to study its genetic basis and molecular mechanism. We characterized 9 secondary metabolite gene clusters that can inhibit the growth of Bacillus . BacillaBacillus . Surfactreported . In addiactivity . Genomic


Background: Idiopathic intracranial hypertension (IIH) affects predominantly obese females during their reproductive age period. The demographics of this condition has not been studied in Kuwait before.Objectives: To determine the demographics, clinical features, risk factors, and treatment modalities of IIH in the main neurology tertiary referral hospital in Kuwait and to compare our data with literature.Methods: A retrospective study was conducted to identify cases of IIH seen between January 1, 2018, and December 31, 2018. Patients were diagnosed in and referred from the neurology and neuro-ophthalmology clinics.Results: Our cohort consisted of 139 patients. We estimated a crude annual incidence rate of IIH of 3.28 per 100,000 population. Female-to-male ratio was 9.6:1. Mean age was 32.1 ± 10.8 years. Mean age of males was 31.46 ± 12.63 and that of females was 32.11 ± 10.67. The median of the duration from the first symptoms till diagnosis was 6 weeks (2–10 weeks). Headache was the most common symptom in 134 (96.4%) patients, followed by visual disturbances in 85 (61.2%) patients, transient visual obscurations (TVOs) in 84 (60.4%) patients, pulsatile tinnitus in 72 (51.8%) patients, diplopia in 22 (15.8%) patients, other symptoms  in 19 (13.7%) patients, and 1 (0.7%) patient had facial weakness. High body mass index (BMI) was seen in 89.9% of patients, either overweight or obese, and it was the most common risk factors in both males (46.2%) and females (61.1%). Anemia was found in 38.1%; 21.6% of patients used OCPs and 7.9% used vitamin A. Bilateral transverse sinus stenosis (BTSS) was detected in 47 (33.8%) patients. Only 2 (1.4%) patients developed “fulminant IIH” characterized by rapidly progressive disease. All the patients received medical treatment and only 12 (8.6%) needed surgical management.Conclusion: Incidence of IIH in Kuwait is similar to other regional studies but higher than Western studies. Demographics and clinical features of IIH in our study are comparable to international and regional figures. Most of our patients had a benign course. IIH is more prevalent in females and strongly associated with obesity. Idiopathic intracranial hypertension (IIH) is a condition characterized by increased intracranial pressure (ICP) with no evidence of space-occupying lesion, meningeal inflammation, or venous thrombosis. It was originally, described by Dandy as “pseudo-tumor cerebri” because of common clinical signs of intracranial hypertension in the absence of tumoral causes .IIH has been strongly associated with obesity and female gender in reproductive age. Symptoms include headache, transient visual obscuration, pulsatile tinnitus, diplopia, and back and neck pain. Papilledema can lead to permanent visual loss if the condition is not treated appropriately in a timely manner. The diagnosis can be delayed since the clinical presentation and symptoms are variable and non-specific . The modThe Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) showed a beneficial effect of acetazolamide and weight loss in patients with mild visual loss .Due to the paucity of large epidemiological, community-based studies, the incidence, prevalence, and clinical characterization of IIH are variable in literature. We studied the demographics, clinical characteristics, risk factors, and management modalities in a hospital-based population of IIH cases in Kuwait.We conducted a retrospective study of patients diagnosed with IIH in Ibn Sina Hospital, the only tertiary neurology, and neuro-ophthalmology referral hospital in Kuwait from January 1, 2018, to December 31, 2018.The state of Kuwait has a population of 4.226 million (2018) with six governmental divisions and six major general hospitals. The incidence was defined as the number of new cases diagnosed with IIH (incidence of diagnosis) per 100,000 individuals.All the medical records in Ibn Sina Hospital at the time of the study were reviewed. Lists of all patients discharged from the hospital with a primary diagnosis of IIH were recorded. Only patients who were diagnosed as IIH according to the revised diagnostic criteria were included .All patients with suspected IIH undergo magnetic resonance imaging and venography (MRI/MRV) to rule out secondary causes of elevated intracranial pressure. All patients had sagittal and axial T1-weighted, T2-weighted and FLAIR MRI of the brain and either phase contrast or time of flight MRV using a three-dimensional phase contrast technique with 40 cm/s velocity encoding  on either 1.5-T or 3-T machine.2O. CSF was analyzed for biochemical and cytological composition. Neuro-ophthalmological evaluation included Snellen visual acuity, refraction, color vision, visual field tests with the Humphrey Field analyzer (HFA), and optical coherence tomography (OCT). Weight and height were measured and recorded in order to calculate body mass index .Lumbar puncture (LP) and CSF manometry were also performed for all suspected IIH cases. LP was performed in the left lateral recumbent position and CSF opening pressure was measured with the legs extended. LP opening pressure is considered to be high if it is equal to or above 250 mm HData on age at onset of symptoms, gender, height, weight, BMI, presence of comorbid conditions, medication use, findings of ophthalmic examination, neurological assessment, CSF opening pressure, radiological signs on cerebral MRI , presence of BTSS on MRV, and type of medical or surgical treatment were recorded from the medical files.The study was approved by the Institutional Review Board Committee of Ministry of Health of the State of Kuwait.We used SPSS software for Windows, Version 23  to calculate range, mean, standard deviation, frequency, and percentage for different variables. The crude incidence rate per 100,000 persons was calculated using the total number of IIH cases included as numerator and the total number of Kuwaiti population as denominator. Ninety-five percent confidence intervals (CIs) were computed. Population data, based on the census carried out in 2018, were obtained from Kuwait Bureau of Statistics to determine the number of people at risk.Chi-square test was adopted for categorical variables. Results were expressed by mean ± standard deviation, median with interquartile range (IQR), or percentage.A total of 139 patients were included in our study during the assigned period. We estimated a crude annual incidence rate of IIH of 3.28 per 100,000 population . Demographics and clinical characteristics of our cohort are demonstrated in One hundred twenty-six (90.6%) were females and 13 (9.4%) were males with a female-to-male ratio of 9.6:1. Family history was positive in 4 patients (2.8%).Mean age of the patients was 32.1 ± 10.8 years, ranging from 12 to 59 years.Mean age of males was 31.46 ± 12.63 and that of females was 32.11 ± 10.67 years.The duration from the first symptoms till diagnosis ranged from 2 to 10 weeks with a median of 6 weeks.Most of the patients were of Kuwaiti nationality [89 (64.0%)], followed by Egyptian nationality [21 (15.1%)] and Indian nationality [10 (7.2%)], and 29 (20.8%) were from other nationalities.Headache was the most common presenting symptom in 134 (96.4%) patients. On a scale of 0–10, the mean of headache severity was 6.5. It was described as classical high-pressure headache in 49 (35.2%) patients, dull aching, holocranial, or pressure-like in 37 (26.6%), chronic daily headache in 31 (22.3%), and migraine-like in 22 (15.8%) patients.Blurring of vision was present in 85 (61.2%) patients and 2 (1.4%) patients developed “fulminant IIH” and visual loss. Transient visual obscuration (TVOs) were reported by 84 (60.4%) patients, pulsatile tinnitus was reported by 72 (51.8%) patients, diplopia was reported by 22 (15.8%) patients, and 19 (13.7%) patients reported other symptoms . One (0.7%) patient had left facial weakness .Neurological examination upon presentation showed bilateral papilledema in 138 (99.3%) patients and only 1 patient with normal fundus exam. Papilledema was mild in 48 (34.8%) patients, moderate in 60 (43.5%) patients, and severe in 30 (21.7%) patients. Seventy-eight (56.1%) patients had a visual acuity of 20/20, 7 (5.0%) patients with 20/400, 2 (1.4%) patients with 20/800, 2 (1.4%) patients with “fulminant IIH” with no perception of light, and 50 (35.9%) patients in between. Sixth nerve palsy was found in 22 (15.8%) patients, of whom 4 (2.8%) had bilateral palsy. One patient (0.7%) had left lower motor neuron facial nerve palsy.Visual acuity, mean deviation of the visual fields (MD), and the retinal nerve fiber layer thickness (RNFLT) obtained by optical coherence tomography (OCT) at presentation are shown in BMI ranged from 19.4 to 58.6. None of the patients had BMI <18.5 (underweight). BMI of 14 patients were between 18.5 and <25 , 40 (28.8%) were between 25 and <30 (overweight), and 85 (61.1%) patients had a BMI of more than 30 (obese). Thirteen (9.4%) patients had no identifiable risk factor despite full workup.Anemia was found in 53 (38.1%) patients. Abdominal ultrasonography was done for all our female patients and polycystic ovary (PCO) was found in 13 (9.4%) patients. Thirty (21.6%) patients were taking oral contraceptive pills while 11 (7.9%) patients reported taking vitamin A (retinol) and isotretinoin for acne treatment.Other common comorbidities among our cohort were hypertension in 27 (19.4%), diabetes mellitus in 11 (7.9%), migraine in 7 (5.0%), and hypothyroidism in 6 (4.3%) patients.2O with a mean of 360 mmH2O. Closing pressure ranged from 120 to 500 mmH2O with a mean of 200 mmH2O. CSF analysis was within normal range for all patients for proteins, 229 mg/dl (100–630); glucose, 3.4 mmol/L (2.3–4.5); and cells, <5 white blood cells. LP needed to be repeated in 28 (20.1%) patients through their course of illness.The CSF opening pressure ranged from 250 to 990 mmHPost-LP headache was reported in 32 (23.0%) patients during the first week after CSF tapping.MRI of the brain was done for all our patients; prominent subarachnoid space around the optic nerves was found in 64 (46.0%) patients, flattening of the posterior sclera in 107 (76.9%), partial empty sella in 79 (69.7%), and slit-like ventricles were seen in only 4 (2.8%) patients .MRV was done for all our patients. Cases with cerebral venous thrombosis were excluded from this cohort. MRV was normal in 92 (66.2%) patients, and it showed bilateral transverse sinus stenosis (BTSS) in 47 (33.8%) patients .Most of our patients, 127 (91.4%), were managed successfully with weight loss and medical therapy, while only 12 (8.6%) patients needed surgical management.Acetazolamide in a dose ranging from 1 to 4 g/day was given to 123 (88.4%) and was well-tolerated. Topiramate was given to 31 (22.3%) patients. Furosemide was given to 5 (3.6%) patients, chlorthalidone to 1 (0.7%) patient, and corticosteroids to 1 (0.7%) patient. Four patients (2.8%) received combination therapy of acetazolamide and topiramate.Seven (5.0%) patients underwent optic nerve sheath fenestration (ONSF), 5 (3.6%) patients underwent CSF shunting , and 1 (0.7%) patient underwent endovascular venous sinus stenting (VSS). Ten (7.1%) patients in our cohort underwent bariatric surgery in addition to medical treatment.There was no significant difference in the clinical and demographic characteristics between male and females. High BMI was the most prevalent risk factor in both genders. Intake of vitamin A was reported only in the female cohort while anemia was reported in both cohorts.IIH is primarily a disorder of young obese women with a worldwide incidence around 12–20 per 100,000 people per year in obese females at childbearing period, but only 0.5–2 per 100,000 people per year in the general population . In thisFew studies have addressed the epidemiology of IIH in the Arab countries and Middle East. One retrospective study from Oman  evaluateFemales constituted the majority of the population in our cohort (90.6%), with a female-to-male ratio of 9.6:1, which is similar to other published studies that found a ratio from 4:1 to 8:1 , 14. A lThe mean age in our study was 32.1 ± 10.8 years , which is similar to Thambisetty et al. , reportiFamily history was positive in 4 patients (2.8%) in our cohort who were all obese. The positive family history percentage varies in the literature between 5.0% in IIHTT participants and 11.3% in the study of Corbett . IIH couSymptoms in our cohort were similar to those found in other previous studies , 18. HeaTVOs are transient episodes of monocular or binocular visual loss usually during postural changes and lasting <30 s followed by full visual recovery. They were reported by 60.4% of our patients compared to 68% in IIHTT participants or 72% in another study .Tinnitus in IIH is usually bilateral and pulsatile in nature. It was reported by 51.8% of our patients similar to several studies that found tinnitus in 50–60% of their cases , 22.In our cohort, 15.8% developed diplopia secondary to either unilateral or bilateral sixth cranial nerve palsy as a false localizing sign . In liteSeventh nerve palsy was seen in one female in our cohort, and it has been reported in the context of IIH in literature in 2–6% of cases , 27. ThePapilledema was found in almost all our patients and one patient only had IIH without papilledema (IIHWOP) who was diagnosed based on elevated opening pressure and neuroimaging criteria. Digre et al.  reportedObesity has a strong association with IIH in most cases and weight loss alleviates IIH signs and symptoms significantly while weight gain is linked to recurrence . Kuwait We reported in our cohort anemia, use of OCPs, vitamin A, and PCOS, which are common among women of childbearing age. In our community, consumption of vitamin A by young ladies is common and may have an impact on prevalence of IIH in our cohort. Vitamin A intake was reported in previous studies of IIH prevalence and morphology . There iHypertension and DM were other common comorbidities in more than a quarter of our cohort. These diseases have high prevalence in obese patients, and this was similar to a recent study from Australia where hypertension was found in 22.7% of IIH patients. However, the highest comorbidities they found were migraine (31.8%) and depression (30%) . PrevaleBTSS was found in 33.8% of our cohort. This finding is much lower than other studies that found BTSS prevalence in the 90% range –38. ThisWeather venous stenosis playing a role in the pathophysiology of elevated pressure is still controversial. However, venous sinus stenting has been shown to be beneficial in IIH in some case series, but its long-term benefits are still unknown . We had Most of our patients (91.4%) needed only medical treatment, which is in line with a recent UK study that reported 91.6% of responders to medical treatment .Our study is the first one that estimated the incidence of IIH in Kuwait. There is only one tertiary hospital in Kuwait that takes care of patients requiring neurology and neuro-ophthalmology care. We collected the required information to calculate the incidence of IIH in Kuwait. This study represents the first comprehensive description of a large IIH cohort from Kuwait.First, being a retrospective study conducted in a single hospital-based population, the results are subjected to bias and lack of generalization. Second, the underreporting of BTSS in our cohort can be attributed to the technique used in MRV rather than actual low prevalence. Another limitation of the study is including cases who have been taking vitamin A, which, according to some authors, should not be considered “idiopathic” and the term “pseudotumor cerebri syndrome” would be more plausible in this situation.Crude annual incidence rate of IIH is 1.6 per 100,000 population. Female-to-male ratio was 9.6:1. Mean age was 32.1 ± 10.8 years. Headache was the most common symptom in 134 (96.4%) patients. High BMI was seen in 89.9% of patients, either overweight or obese, and it was the most common risk factor in both males (46.2%) and females (61.1%). BTSS was detected in 47 (33.8%) patients. All the patients received medical treatment and only 12 (8.6%) needed surgical management.Incidence of IIH in Kuwait is high in comparison to Western countries and this is in line with increasing obesity rates in our region. The clinical presentation, risk factors and management of IIH in our study are comparable to the international and regional studies of IIH. Most of our patients had benign course. IIH is more prevalent in females and strongly associated with obesity.All datasets generated for this study are included in the article/supplementary material.This study was approved by the Institutional Review Board Committee of Ministry of Health of the State of Kuwait.All authors collected and analyzed the data and wrote and reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There was a concordance in 33.1% of cases (n = 59). We had a poor agreement between the MRI and final histopathological examination with an adjusted kappa (κ) of 0.12 [95% IC ]. There was a moderate concordance on the grade between the pretherapeutic biopsy and the final histopathological examination on excised tissue with an adjusted kappa of 0.52 [95% IC 0.42–0.62)]. Endometrial biopsy underestimated the tumor grade in 28.9% of cases (n = 50) (p < 0.001), overestimated the tumor grade in 6.9% of cases (n = 12) and we observed a concordance in 64.2% of cases (n = 111). Conclusion: The pre-operative assessment of endometrial cancer is inconsistent with the results obtained on final histopathological examination. A study with a systematic review should be done to assess the performance of MRI, only in expert centers, in order to consider a a specific care management for endometrial cancer patients: patients who have had an MRI in an outpatient center should have their imaging systematically reviewed, with the possibility of a new examination in case of incomplete sequences, by expert radiologists, and discussed in multidisciplinary concertation meeting in expert centers, before any therapeutic decision. The sentinel node biopsy must be used for low and intermediate risk endometrial cancer.Objective: The aim of this retrospective cohort study is to evaluate the concordance between the preoperative MRI and histology data with the final histopathological examination. Method: This is a retrospective observational study of 183 patients operated for endometrioid cancer between January 2009 and December 2019 in the surgical oncology department of the Lorraine Cancer Institute (ICL) in Vandœuvre-lès-Nancy. The patients included are all women operated on for endometrioid-type endometrial cancer over this period. The exclusion criteria are patients for whom the pre-therapy check-up does not include pelvic MRI and those who have not had first-line surgery. The final anatomopathological results were compared with preoperative imaging data and with endometrial biopsy data. Results: For the myometrial infiltration, the sensitivity of MRI was of 37% and the specificity of 54%. To detect nodal metastases, the sensitivity of MRI was of 21% and the specificity of 93%. We observed an under estimation of the FIGO classification ( Endometrial cancer (EC) is the most common gynecologic cancer in France with 8220 new cases in 2018, ranking fourth among cancers in women. The overall survival is 75% at 5 years and 68% at 10 years owing to an early diagnosis permitted by vaginal bleedings. This prognosis and the risk of recurrence is linked to lymph node infiltration with an overall survival at 5 years of 89.6% at stage I compared with 49.4% at stage IIIC  (The MRI underestimated the FIGO stage in 42.7 % of cases (n = 76) ] .2 compared to 39.6 kg/m2 for women with a discordance (p = 0.05). Focusing on myometrial invasion, there was a poor match between the MRI and final histopathological examination with an adjusted kappa of −0.08 [95% IC ].Women with a concordance between MRI and final histopathological examination on FIGO stage had a median BMI of 35.3 kg/mp = 0.144) ]. On the 128 performed lymphadenectomies, we observed an under estimation of MRI on nodal metastases in 11.8% of cases (n = 15), an overestimation in 6.3% of cases (n = 8), and a concordance in 81.9% of cases (n = 105). There was no statistical difference between the frequency of cases with nodal metastases on MRI and final histological examination (= 0.144) .2 for 57% for women with a discordance (p = 0.037).Among women with concordance for nodal extension evaluation on MRI and histopathological examination 64% had a BMI higher than 35 kg/mThere was no significant difference for the presence of other abnormalities on MRI on the uterus as fibroma, myoma, endometriosis, or internal material which could explain this mismatch on FIGO stage and myometrial invasion.There was a moderate concordance on tumoral grade between the pretherapeutic biopsy and the final histopathological examination on excised tissue with an adjusted kappa of 0.52 [95% IC 0.42–0.62)].p < 0.001), overestimates the tumor grade in 6.9% of cases (n = 12), and we observed a concordance in 64.2% of cases (n = 111)  (n = 111) .p = 0.005)  and by hysteroscopy in 92 cases (53.2%). The biopsy performed by Cornier pipelle overestimated the tumor grade in 16.0% of cases (n = 13) and underestimated the tumor grade in 39.5% (n = 32) with a concordance in 58.0% (n = 47). Biopsies performed by hysteroscopy overestimated the tumor grade in 10.9% of cases (n = 10) and underestimated the tumor grade in 19.6% (n = 18) with a concordance in 69.6% of cases (n = 64). Biopsies by Cornier pipelle had more discordance than biopsy by hysteroscopy on grade evaluation (= 0.005) .p = 0.041), 42.1% (n = 8) had a grade 2 tumor and 5.3% (n = 1) had a grade 1 tumor. Twenty-five percent (n = 46) of women had LVSI on final histopathological examination and among these women 24% (n = 11) had nodal metastases and 60.1% (n = 28) had no nodal metastases (p = 0.004).Furthermore, 52.6% of women with nodal metastases (n = 10) had a grade 3 tumor  on the postoperative data. In total, of the 66 lymphadenectomies indicated on the preoperative data, 58 were performed (45.3%). Seventy were performed without any indication on the preoperative data (54.7%).One hundred and twenty-eight lymphadenectomies were performed, 20 (11%) had both pelvic and para-aortic lymphadenectomies 108 women (59.7%) had a pelvic lymphadenectomy alone. Nineteen (10.4%) women had nodal metastases, 3 (1.6%) had both pelvic and para-aortic metastases, 15 (8.2%) had pelvic metastases alone, and 1 (0.5%) had para-aortic metastases alone.For 6 women of these 19 women (31.6%) with nodal metastases, the lymphadenectomy was not indicated with the pretherapeutic data.For 50 women (27.3%) lymphadenectomy was indicated on preoperative and postoperative data. For 16 women (8.7%) lymphadenectomy was indicated on preoperative data and not indicated on post-operative data. Among these women with an indication of lymphadenectomy, 58 (87.9%) had a lymphadenectomy and 13 (19.7%) had nodal metastases.Lymphadenectomy was not indicated in both preoperative and postoperative data for 64 women (35.0%) and was not indicated on preoperative data but on postoperative data for 42 women (23.0%). Among these women with no indication of lymphadenectomy on preoperative data, 70 (66.1%) had a lymphadenectomy and 6 (8.6%) had nodal metastases . All womp = 0.012). We did not observe a significant difference in the ASA score (p = 0.333) or in the age (p = 0.85).Women with absence of para-aortic lymphadenectomy had a higher BMI than women with both pelvic and para-aortic lymphadenectomy  and higher specificity (81% vs. 54%) for evaluation of myometrial invasion by MRI . These dIn fact, several MRI were not performed by expert center and every imaging center did not execute an axial section in T2, which evaluates the extension of the junctional area with the myometer and dynamic sequences in T1 with injection, which precise the depth of myometrial infiltration, especially for postmenopausal women . The lacConcerning our observation finding a higher BMI in women with a discordance between FIGO stage on MRI and on histopathological examination, we do not find to date any studies evaluating obesity as a factor influencing MRI images or finding this characteristic.For lymph node evaluation, the sensitivity of MRI was 21% and the specificity was 93%. Lymph node metastases are determined by the augmentation of lymph node volume in MRI, but sensitivity was variable in literature from 17.0% to 70.6% .To confront this insufficient MRI performance, several studies evaluated the performance of PET-TDM in detection of nodal invasion. This examination showed a higher sensitivity (83.3% vs. 38.9%) and lower specificity (51.2% vs. 96.3%) than MRI in detection of pelvic metastases ,29. HoweIn order to avoid surgical complication, several studies evaluated the performance of sentinel-node biopsy in endometrial cancer, especially in early stages. It showed a sensitivity from 84% to 97.2% and a negative predictive value from 97% to 100% with a lower morbidity ,33,34,35We found a moderate concordance on the grade between the pretherapeutic biopsy and the final histopathological examination on excised tissue with an adjusted kappa of 0.52 [95% IC 0.42–0.62)]. Several studies showed a wrong correlation on the grade between the endometrial biopsy and the final histopathological examination .This discordance was mostly observed from grade 1 to grade 2. In fact, studies showed a better concordance between pre-operative samples and final histopathological examination for high grade in comparison to low and intermediate grades ,40. AlthThe significant downgrading on endometrial biopsy could be explained by the different proportion of solid tumor and the heterogeneity of the tumor. Indeed, the proportion of nuclear atypia and differentiation is variable in the same tumor and depends on the sample. This bias could be reduced by multiple samples. Moreover, several samples were examined in external centers, which highlighted the inter-observer variability and poor reproducibility ,42.However, the pre-operative examination was more concordant with the final histopathological examination in case of sample realized by hysteroscopy . There wThis was a monocentric and retrospective study. At least three generations of MRI machines were use in the reference center from 2009 to 2019, each generation leading to a better signal with less artefact. This could contribute to wrong estimation of local invasion on MRI. Several MRI and endometrial biopsies were examined in external centers which could be linked to a lack of experimentation in the interpretation.The combined method by PET-MRI is on evaluation and primary observational studies showed at least an equivalence between PET-MRI and PET-TDM for the diagnosis of endometrial cancers and regional metastases ,47. FernThe pre-treatment assessment of endometrial cancer is not consistent with the results obtained on histopathological examination.A systematic re-reading of the imaging must be carried out in an expert center by radiologists trained in the pathology, and this treatment must be integrated into a specific care management for endometrial cancer patients, in order to decide on the best therapeutic plan in multidisciplinary concertation meeting in expert centers.The sentinel node technique, performed in groups considered low and intermediate risk, is developing and is necessary in view of the poor imaging performance.


Knowledge, Attitude and Behavior of Mothers about Prevention of Childhood Accidents and Injuries in Under-6-year-old Children Background: injury and violence prevention in “healthy people project 2020”, has been considered as one of the most important factor to improve health promotion. Parents are directly responsible for the children health and can play an important role in preventing of childhood accidents and injuries. Purposes: The aim of this study was to assess knowledge, attitude and behavior of mothers in the prevention of childhood accidents.This cross-sectional study that was carried out on 450 mothers of children less than 6 years old referred to health centers in Tabriz, 2016. Data was collected using a validated questionnaire including demographic characteristic (6 items), knowledge (15 items), attitude (5items) and behavior (13items) of mothers about prevention accidents and injuries in children. SPSS Ver-16 statistical software was used to analyze the data. The significance level of α = 0/05 was considered for all tests.The mean age of mothers was 28.2 (SD=5) and children 4.6 (SD=1.5). According to the results 24% of mothers were in higher education and majority of the mothers (88%) were housewives. About 26.5 of mothers had poor, 44.7% moderate and 28.8% good knowledge about preventing accidents and injuries in children. The mean (SD) attitude score was 8.4 (3.8) and 75.8% of mothers had high attitude. Mothers’ behavior related to childhood accidents were Poor (15%), average (35.8), and good (27.7%). The overall prevalence of injury among children was 38%. The most reasons for injury were falling (55.1%), burns (19.8%) and poisoning (8.4%). The knowledge (p<0.01) and attitude (p<0.05) had a meaningful relationship with the behavior of mothers about prevention of childhood accidents and injuries. There was statistically association between mothers knowledge and education level .According to the results of this study, mothers’ knowledge and behavior was not desirable about prevention of childhood accidents and injuries. Health promotion interventions based on mothers training needs seem necessary. So it is important to increase families’ knowledge through community –based intervention.Behavior, Knowledge, Accidents, Injuries, Children


Above 80% of urinary tract infections are caused by enteric bacteria, which are known for years by their drug-resistant ability. Though the prevalence of drug-resistant strains is increasing in the world, it is not well known in low-income countries. The aim of this study was to assess the prevalence of Multi-drug resistance, Extended-spectrum β-lactamases production, and associated risk factors among pregnant women in Northwest Ethiopia.A hospital-based cross-sectional study was conducted among pregnant women from March to May 2017. A total of 384 clean-catch midstream urine sample was collected from study participants. Bacterial identification and drug susceptibility testing were done following standard microbiological techniques; Extended-spectrum β-lactamase production was screened using a disc diffusion test and confirmed by a combination disc test. The data were entered and analyzed by using SPSS version 20, and a p-value of less than 0.05 was considered as statistically significant.E. coli (49.2%), CoNS (27.9%), and S. aureus (18%) were the main uropathogens. The prevalence of MDR uropathogens was 60.65%. The prevalence of ESBLs production among cases caused by Enterobacteriaceae was 18.2%. The drug resistance rate of Gram-negative isolates was higher for ampicillin (90.9%), cephalothin (84.8%), and augmentin (57.6%). The drug nitrofurantoin showed the highest activity (100%) against Gram-negative isolates. Gram-positive isolates were showed low susceptibility to penicillin (89.3%) and cotrimoxazole (75%); however highest susceptibility rate for gentamicin (100%), amikacin (100%), and nitrofurantoin (98.36%) was recorded. Prior antibiotic therapy  was a risk factor for the presence of multi-drug resistant bacteria.The overall prevalence of urinary tract infection was 15.9% (95% CI 12.8–20.1%). The multi-drug resistance prevalence was high among uropathogen, thus treatment of urinary tract infection during pregnancy; should be based on the antibacterial susceptibility testing result. The isolation of drug-resistant strains like Extended-spectrum β-lactamases in this study calls for the need of periodic and continuous follow-up of antibiotic usage among pregnant women. Nitrofurantoin, gentamicin, amikacin, and ciprofloxacin/norfloxacin showed higher activity against bacterial uropathogen. Urinary tract infection (UTI) is an infection involving urinary tract structures . The uriEnterobacteriaceae, in particular, E. coli accounted for about 90% of these infections [Antibiotic resistance is a growing problem across the world, and indiscriminate use of drugs increases its evolution , 15. It fections . During fections –26. Multfections .Enterobacteriaceae are the leading isolates responsible for the infection [In Ethiopia, UTI among pregnant women is very common with a reported prevalence between 9.2% and 18.8%; nfection –33. The nfection . TherefoA hospital-based cross-sectional study was conducted from March to May 2017 at the University of Gondar Hospital (UoGH), Northwest Ethiopia. This referral teaching hospital is one of the biggest hospitals in the Amhara region. About five million people, from the surrounding areas, visit this hospital for different medical services. The study population was pregnant women, who were not on antibiotic treatment for the last 2 weeks from the data collection day, visiting the ANC unit of the hospital.The sample size of this study was 384. Since there is no clear data on the prevalence of ESβLs producing strains or MDR bacteria among pregnant women, a single population proportion formula, taking p as 50%, was used to calculate the sample size. The systematic sampling technique was applied to select the study participants. Sampling interval was calculated from the sampling frame, estimated number of ANC attendants during the study period. The first study participant was selected using lottery method.All the study participants were interviewed face to face by trained data collectors (midwives), using a structured and pretested questionnaire, to collect data on the socio-demographic, clinical, and pregnancy-related characteristics. Finally, instruction on how to collect clean-catch midstream urine samples was given to the pregnant women; ~10–20 ml of urine specimen was collected using a sterile screw-capped, wide-mouthed container. The container was labeled with unique code, date, and time of collection then sent to the microbiology laboratory for processing and testing .5 CFU/ml of urine was considered as significant bacteriuria. The identification of the culture-grown bacteria was based on the gram staining, colony characteristics, and biochemical reactions [The urine specimen was first inoculated on Cysteine-Lactose-Electrolyte-Deficient (CLED) agar using a sterile loop measuring 10 µl then later colonies from CLED agar were subjected to gram staining procedure and then sub-cultured on MacConkey and Blood agar plates . The plates were incubated in the appropriate atmosphere at 37 ℃ for 24–48 h overnight. A colony count of ≥ 10eactions . The AnaAntibiotic susceptibility testing was carried out using the disc diffusion method. The bacterial suspension was made; its turbidity was adjusted to a 0.5 McFarland turbidity standard before inoculated over the entire surface of Muller Hinton agar . In thisAll isolates showing reduced susceptibility to either of the 3rd generation cephalosporins  were selected using disc diffusion method. Those isolates then subjected to a phenotypic confirmatory test for ESβLs detection . A combiE. coli ATCC 25922, P. aeruginosa ATCC 27853, and S. aureus ATCC 25923. The sterility of the prepared media was checked by incubating 5% of the batch overnight at 37 °C. For ESβL positive control, K. pneumoniae ATCC 700603, and ESβL negative control, E. coli ATCC 25922 strains were used [A pre-tested and structured questionnaire was used to collect socio-demographic, pregnancy, and clinical-related factors. Standard Operating Procedures (SOPs) were strictly followed during all the stages of sample collection and laboratory work. Reference strains used in this study were The data was entered into SPSS version 20 and was double-checked before analysis. Appropriate descriptive statistics for demographic, clinical, and pregnancy-related characteristics were calculated. The bivariable logistic regression model was fitted for each independent variable. Moreover, those variables having a p-value < 0.2 in univariate analysis were fitted into the multivariable logistic regression model. Odds ratio with a 95% confidence interval and p-values were used to measure the strength of association and to identify statistically significant associated factors, respectively. In multivariable analysis, variables having a p-value < 0.05 were considered to have a statistically significant association with MDR bacterial infection.A total of 384 pregnant women were participated in the present study with the age ranges of 15–45 and a mean (standard deviation) age of 26 (± 5.4). About 349 (90.9%) of the study participants were Orthodox Christians, 305 (79.4%) were urban, and 365 (95%) were married. About 128 (33%) of the participants were illiterate, 167 (43.5%) were housewives, and 110 (28.6%) had monthly income ≤ 1000 birr  and 119 (31%) were on their 3rd and 2nd trimester, respectively. Based on parity, 224 (58.3%) of the women had more than one pregnancy experience, and 176 (45.8%) of them were nulliparous. Of the total study participants, 26 (6.8%) had a history of prior hospitalization, 62 (16.1%) had a history of previous UTI, and 88 (22.9%) had prior antibiotic therapy. 3.4% of pregnant women had HIV infection. The number of pregnant women with a symptom/s of UTI was 122 (31.8%) (Table E. coli 30 (49.2%) was the commonest uropathogen, followed by CoNS 17 (27.9%) and S. aureus 11 (18%). The prevalence of MDR among uropathogens was 37 (60.65%). About 13 (76.47%) of the CoNS and 17 (56.67%) of the E. coli isolates were MDR. The prevalence of ESβLs production among Enterobacteriaceae was 6 (18.2%). E. coli and Enterobacter cloacae were the two ESβL producing isolates. Among Gram-positive isolates, 4 (36.36%) of the S. aureus were MRSA, and 8 (47.06%) of the CoNS were resistant to methicillin ). Of isolated uropathogens, The prevalence of UTI among symptomatic and asymptomatic cases was 38/122 (31.1%) and 23/262 (8.8%), respectively. The Fisher’s exact test showed that history of hospitalization, previous history of UTI, and prior antibiotic therapy were associated with the presence of UTI. The prevalence of MDR bacteria was 25/38 (65.8%) and 12/23 (52.2%) among culture-positive symptomatic and asymptomatic participants, respectively. The prevalence of MDR was significantly higher (p < 0.05) among study participants who had a history of antibiotic therapy than those who hadn’t. Table .Table 4POnly 2/61 (3.28%) of bacterial isolates were sensitive to all antibiotics used in this study. The 14 22.95%), 16 (26.23%), and 19 (31.15%) of the isolates were resistant to two, three, and at least five of the antibiotics tested, respectively , cephalothin 25 (83.33%), and augmentin 17 (56.7%). None of the Gram-negative isolates were resistant to nitrofurantoin, and none of the Gram-positive isolates were resistant to gentamicin and amikacin. Among the Gram-positive isolates, Staphylococcus saprophyticus was the only one resistant to nitrofurantoin. The resistance rate for cefoxitin was 36.4% among S. aureus, and 47% among Coagulase Negative Staphylococcus (CoNS) isolates  when compared to resistance rates by non-ESβLs producing isolates. All the ESβLs and most of the non-ESβLs producing strains were resistant to ampicillin and cephalothin. Uropathogens producing ESβLs were sensitive to nitrofurantoin; most of them were susceptible to fluoroquinolones Table .The only variable that remained an independent factor for the presence of MDR bacterial infection among pregnant women was a prior history of antibiotic therapy   in this study was in agreement with previous studies in eastern Ethiopia (14%)  and in TE. coli 49.2%, followed by CoNS 27.9% and S. aureus 18.03%. Previous reports from different regions of Ethiopia have also reported similar findings [The most prevalent uropathogen identified was findings , 31, 33.findings , where CIn the present study, the prevalence of MDR bacteria was 60.65%. This study reported a lower prevalence than previous studies in the same study area, 68% in 2002 , and 95%Enterobacteriaceae. Hence, the prevalence of ESβLs was 18.2%. This prevalence was lower than previous reports in Ethiopia, which was between 25 and 38.4% [The present study was also aimed to assess the prevalence of ESβLs production among nd 38.4% –44. Reasnd 38.4% . On the nd 38.4%  and Pakind 38.4% . This diE.coli was 16.7% and it is incompatible with a report by Olufunke et al. in Nigeria [E. coli was identified in Jimma by 2012 [At species level, this study revealed that the prevalence of ESβLs producing  Nigeria . This pr by 2012  and 2015 by 2012 , respectIn the present study, about 90%, 84.8%, and 57.6% of gram-negative uropathogens were resistant to ampicillin, cephalothin, and augmentin, respectively. Previous reports from different parts of Ethiopia also showed a high resistance rate to ampicillin and augmentin , 31. TheWe reported that drugs like nitrofurantoin, gentamicin, and amikacin were effective against uropathogens, followed by norfloxacin and ciprofloxacin. Thapa et al.  reportedIn the present study, all ESβLs producing isolates were sensitive to the drug nitrofurantoin. The same thing happened in Nepal by Thapa et al.  and Sri History of antibiotic usage was the only variable associated with the presence of MDR uropathogens. The previous study in Ethiopia also reported the use of antibiotics as a risk factor for acquiring MDR bacteria . Other sThe study was done in the hospital setting so that the result may not be representative of other pregnant women attending other health sectors in the same area. Associated factors for MDR bacterial infection were not fully addressed because of the absence of participants with factors like catheterization, and chronic diseases like diabetes mellitus. The number of isolates was small, and this may affect the estimation of the prevalence of ESβL producing strains among pregnant women.Antibiotics like nitrofurantoin, ciprofloxacin, and norfloxacin were effective against gram-negative uropathogens, including ESβL producers. Gentamicin, amikacin, and nitrofurantoin were effective against staphylococcus species, which causes UTI. The prevalence of MDR was high among uropathogens, which calls for the use of AST results to treat UTI during pregnancy. The presence of Multi-drug resistant bacterial infection during pregnancy was associated with prior antibiotic therapy. The isolation of ESβLs producing uropathogens and methicillin-resistant staphylococcus species in this study calls for the need of periodic and continuous follow-up of antibiotic usage during pregnancy. Moreover, conducting molecular studies will help to characterize the various drug-resistant strains.


TIR3B thyroid nodules are considered to be at risk of malignancy (15–30%) but guidelines recommend conservative surgery with lobectomy with primary diagnostic porpoise. Risk stratification mainly based on ultrasound, elastography and genetic mutations usually may influences the surgical approach.P values less than 0.05 as significant.We retrospectively analyzed 52 cases of TIR3B underwent between 2015 and 2017 total thyroidectomy (TT) and lobectomy (L), focusing mainly on the observed rate of malignancy. Chi-squared test and Fisher’s exact probability test were used for analysis, considering a Out of 52 patients 49 underwent TT and 3 L. In TT group a multinodular goiter was associated in 67.3% of patients. Malignancy rate was 81.6 and 33.3% respectively after TT and L (P 0.003). Multicentric and contralateral tumors were detected respectively in 36.7% and in 32.6% of patients underwent TT. No main post-operative complications were registered.Ultrasound and elastography are useful to define within the TIR3B group those lesions at higher risk and therefore requiring a more radical approach. TT seems an appropriate approach to TIR3B lesions, especially in multinodular goiter, considering the incidence of malignancy with probably higher rate than previously reported. In 2014, the Italian Society for Anatomic Pathology and Cytology (SIAPEC) together with the Italian Thyroid Association (AIT) modified the previous thyroid cytology classification of 2007, by replacing the TIR3 class with two new subclasses, TIR3A and TIR3B comparable respectively to the Bethesda category AUS/FLUS and FN/SFN . Recent S. Maria University Hospital, Terni, University of Perugia, Italy, referral centre of Umbria region , by the same surgical team, with standard surgery for both total thyroidectomy (TT) and lobectomy (L). The diagnostic work out adopted standard technique as US, RTE and cytology. Molecular analysis was available in a limited number of patients (5 cases) and therefore not considered for the present study. Risk stratification was done in all cases. US features of the nodule were evaluated in terms of cancer risk according to ATA guidelines [We retrospectively analyzed 52 cases of follicular proliferation classified as TIR3B according to SIAPEC 2014, treated between January 2015 and December 2017 in the Unit of Endocrine Surgery, idelines . Size laidelines , 11 was P values less than 0.05 were considered as statistically significant.The statistical comparison between groups was performed by using chi-squared test and Fisher’s exact probability test. n = 40) and in 33.3% (n = 1) respectively after TT and L (P 0.003), with a cumulative malignancy rate of 78.8% (41 out of 52 patients). Only 6 patients out of 49 undergone TT, presented a an isolated low risk, T2 (< 4 cm) carcinoma. The patient with carcinoma after L was treated with contralateral surgery after 2 months. Main size of the TIR3B nodules was 1.7 cm. Size larger than 2 cm was not significantly associated to presence of carcinoma (P 0.057) in the TT group. Among malignant TIR3B a microcarcinoma, less than 1 cm in main diameter, was detected in 15 (36.5%) patients. Out of 49 patients, TT allowed detection of multicentric tumor in 18 (36.7%) cases and in 16 (32.6%) a contralateral carcinoma was detected. The principal histology detected was follicular variant of papillary carcinoma in 37 cases out of 41 (92.6%). High preoperative risk of the TIR3B lesions stratified on US feature, RTE and clinical behaviour fitted the diagnosis of carcinoma in 36/41 patients (87.8%). No main post-operative complications were registered. No recurrent laryngeal nerve lesions were observed after both TT and L. Only 3 cases of transient hypoparathyroidism were observed in the TT group.Out of 52 patients, 34 females and 28 males, presenting at admission a TIR3B lesion, 49 underwent TT and only 3 thyroid L. In TT group a multinodular bilateral goiter was associated in 33 (67.3%) patients, all patients of the L group presented uninodular goiter. Malignancy was detected in 81.6% (The new SIAPEC classification of 2014, assign to TIR3B lesions, referable to the Bethesda FN/SFN group, an higher risk of malignancy compared to TIR3A, based on the evidence of mild/focal nuclear atypia , based oThe decision on what is the best treatment to propose to our TIR3B patients, although affected by several variables and sometimes weak risk stratification criteria, represents both for patient and surgeon a decisional conflict . This coOur data and recent publications show an increased rate of TIR3B lesions with associated higher malignancy rate than expected. This evidence might recommend a radical approach to TIR3B nodules by TT differently to what stated by ATA guidelines which considers conservative surgery with L with diagnostic primary porpoise. Risk stratification based on US pattern, size, clinical behaviour, genetic mutations supports, in clinical practice, the choice of the more appropriate surgery. The presence of concomitant multinodular goiter and risk for bilateral and multicentric tumors are the main factors supporting the choice for a TT in TIR3B. The above considerations must be otherwise analyzed in the general scenario of the recent approach to thyroid cancer for which after a risk stratification, less invasive forms and microcarcinoma are referred to observation or L rather than to TT as in the past.


Trachoma is a contagious infection of the eye. World Health Organization recommended three rounds of mass drug administration in districts where the prevalence of trachomatous follicular (TF) is ≥10% in children aged 1–9 years. Mass drug distribution was given to residents for three consecutive years with more than 90% coverage. However, the prevalence and associated factors of active trachoma in the study community after the intervention was not yet determined. Thus, this deals with the prevalence and associated factors of active trachoma among children aged 1–9 years.p-value < 0.05 for the final model.We conducted a Community based cross-sectional study among 502 children aged 1–9 in March 2018 in Deguatemben. A multi-stage sampling technique was applied. Selected children were examined for trachoma using 2.5x binocular loupe and graded based on the WHO simplified grading system. Mothers were interviewed for factors associated with trachoma using a structured questionnaire. Data was entered on Epi-Info and exported to SPSS for analysis. Both descriptive and inferential analyses were done with 95% confidence intervals (CIs) at a The prevalence of active trachoma was found 21.5% (95% CI: 17.8–25.1%). Being 1 to 4 years old [AOR (95% CI) = 6.81(2.00–23.11)], not washing face [AOR (95% CI) =9.31(1.13–77.66)], not using soap [AOR (95% CI) =5.84(1.87–18.21)], unclean face [AOR(95% CI) = 18.22(4.93–69.32)] and mother’s knowledge [AOR (95% CI) =0.06(0.02–0.19)] were found as independent predictors.The prevalence declined from the baseline, but it is still a public health problem in the district. Personal-related factors were found to be associated with the disease. Health education of “Facial cleanness” and related factors is recommended to increase knowledge of the mothers on their children’s care in addition to the provision of antibiotics. Trachoma is the leading cause of blindness resulted from repeated trachoma infection . Infecte), Trachomatous inflammation intense (TI), Trachomatous scarring (TS), Trachomatous trichiasis (TT) and Corneal opacity (CO) .Out of 502 children who participated in the study 432 (86%) self-reported from mothers to have received at least one round of azithromycin during previous MDA campaigns. Out of 432 children who received azithromycin during previous MDA 359 (83%) received three rounds. The prevalence of active trachoma (TF and or TI) among study participants was 21.5% (95% CI: 17.8–25.1%) in the study community. The prevalence of TF was 18.7%, TI 2.2 and 0.6% were TF and TI co-infected. The prevalence of active trachoma was slightly higher among males (52%) than among females (48%) study participants.p-value of ≤0.25 considered for multivariate regression analysis [Table ]. On multivariate logistic regression, the odds of having active trachoma was found five times [AOR (95% CI) = 5.01(1.79–13.96)] higher among children 1 to 4 years old than children 5 to 9 years old. The logistic analysis also revealed that the odds of having active trachoma were almost six times [AOR (95% CI) =5.84(1.79–13.96)] higher among children who don’t use soap for face washing than their counterparts. The odds of active trachoma was more than nine times [AOR (95% CI) =9.35(4.93–67.32) higher among children who do not wash their face in daily bases compared to those who wash more than once per day. Children with unclean faces were more than eighteen times [AOR (95%CI) = 18.22(4.93–69.32)] more likely to have active trachoma than children with a clean face. The odds of having active trachoma was also 0.06 [AOR (95% CI) =0.06(0.02–0.19)] times less likely among children from mothers with good knowledge than children whose mothers were less knowledgeable. [Table 4].All independent variables were found statistically significant in chi-square (X2) cross-tabulation/bivariate analysis at the is Table . On multThe prevalence of active trachoma in the district was found to be 21.5% (17.8–25.1%) 1 year after three rounds of mass drug administration. Though there is a decline in the prevalence of TF from 44.7% in the baseline to 18.7% after three rounds of MDA, it is far above the 10% treatment threshold . This miThe prevalence of active trachoma in our study area was consistent with finding from district level studies in different parts of the country including; Baso Liben 24.1%, Gongi Kollela 23.1%, Demba 18%, Kersa 25.2%, Dera 18.6%, Cheha districts 22.8% and Maksegnit Town 23.8% , 19–23. In contrast, the prevalence of active trachoma among children in our study is higher than the study findings of Ghana 5.6 and 3.5%, and Gambia 2.8% after control activities , 26. BesActive trachoma was five times more likely to happen among children from 1 to 4 years old than children 5 to 9. This finding is in line with the findings of the study conducted in Ankober and southern nations and nationalities people (SNNP) , 28. ThiChildren who do not use soap for face washing were almost six times to have active trachoma than their counterparts. This finding was in line with the study finding conducted in Baso Liben district . This miChildren who do not wash their faces on a daily bases were found to be more than nine times to have active trachoma compared to those who wash their faces more than once per day. This result is consistent with the study findings of Baso Liben, Gonji kollela, Gazigeabella, and Zala districts , 19, 21.The finding of this study also revealed that children with unclean faces were more than eighteen times to have active trachoma than their counterparts. Other studies also reported similar findings which include; a study conducted in Dembia and Cheha districts , 16. ThiChildren from knowledgeable mothers were found to be 0.07 times less likely to have active trachoma compared to children from less knowledgeable mothers. This finding was in line with the study result from Baso Liben and Zala districts , 19. TheAs the strength of our study, Tetracycline eye ointment was provided to those who had active trachoma two tubes to apply for 6 weeks. Being community-based cross-sectional and the grading of trachoma was done by certified, having more experience in trachoma grading and participated in the pre-intervention assessment of the global trachoma mapping project in the Tigray region. However, the study might have some limitations that first; the cross-sectional nature of the study design does not confirm the definitive cause and effect relationship. For those children who are older, we have not taken into consideration their practice on face washing. The questionnaires were designed and translated into a local language and re-translated to English. This could be also a recipe for bias. Furthermore, the study may prone to reporting bias since some of the data are collected based on self-reported information.Although the prevalence of active trachoma among 1–9 years old children indicate a decline 1 year after three rounds of MDA in the district, it is still higher than the WHO threshold prevalence of 20% which is used to determine trachoma as a severe public health problem and it is far from the elimination of trachoma as a public health problem in a community as when there is less than 5% active trachoma in children , 33. NotThe regional health bureau and woreda health office should implement all components of the SAFE strategy emphasizing personal hygiene  and environmental improvement.


In Zambia, ARI accounts for 30-40% of children's outpatient attendance and 20-30% of hospital admissions. We assessed trends and factors associated with ARI among under-five children in Zambia from 1996 to 2014.we analysed the Zambia demographic and health survey data for 1996, 2002, 2007 and 2014 of under five children and their mothers. We extracted data using a data extraction tool from the women's file. We analysed trends using chi square for trends. We conducted a complex survey multivariable logistic regression analysis, reported adjusted odds ratios (AOR) 95% confidence intervals (CI) and p-values.we included a total of 6,854 and 2,389 (8%) had symptoms consistent with ARI. A 2% upward trend was noted between the 1996 and 2002 surveys but a sharp decline of 10% occurred in 2007. The chi2 trend test was significant p < 0.001. Children whose mothers had secondary or higher education were less likely to have ARI (AOR 0.30 95% CI 0.15-0.58) compared to those with no education. Underweight children had 1.50 times increased odds of having ARI (AOR 1.50 95% CI 1.25 - 1.68) compared with children who were not. Use of biomass fuels such as charcoal (AOR 2.67 95% CI 2.09 - 3.42) and wood (2.79 95% CI 2.45 -3.19) were associated with high odds for ARI compared to electricity.the prevalence of ARI has declined in Zambia from 1996 to 2014. Factors associated with occurrence of ARI included being a child under one year, underweight, use of biomass fuel such as charcoal and wood. Interventions to reduce the burden of ARI should be targeted at scaling up nutrition programs, as well as promoting use of cleaner fuels. Acute respiratory infection is an acute disease affecting the lungs causing fluid and inflammatory waste to accumulate covering alveolar, inhibiting gaseous exchange and leading to difficult and painful breathing . ARI affThe health management information system (HMIS) report of 2016-2017 shows ARI among the top ten causes of morbidity among under five children accounting , 8-10. CWe conducted a cross-sectional study using nationally representative Zambia demographic and health surveys of 1996, 2002, 2007 and 2014. Sociodemographic, socioeconomic and environmental data from the women´s file was extracted for analysis. Details of the ZDHS design are described elsewhere , 12. SocA weighted survey analysis was done and a design effect of 1.490  was usedA total of 30,391 children under 5 years were analysed from 1996, 2002, 2007 and 2014 ZDHSs. A total of 6,854 (23%) children were reported to have had cough two weeks preceding the survey. Out of these, only 2,389 (8%) had symptoms consistent with ARI. Of these 50.2% were females and majority 21,274 (70%) lived in rural areas. The mean age of the children was 28 months. Majority 22,185 (73%) of the mothers were aged between 20-35 years and more than half 16,715 (55%) were working. The most common type of cooking fuel was wood 13,979 (46%) and only 19% of the households had electricity , Table 2At bivariate analysis, an increase in mother´s age and higher level of education were associated with a decreased chance for ARI  (OR 0.27 95% CI 0.17 - 0.40 p -< 0.001) compared with young mothers and those with no education . Breast Multivariable analysis of factors associated with ARI among under five children: at multivariable logistic regression, children whose mothers´ were older than 20 years had a reduced odds of having ARI (AOR 0.68 95% CI 0.52-0.89 p- 0.005) as compared to mothers younger than 20 years after controlling for education level, underweight, child´s age, vitamin A and overcrowding. Children whose mothers had higher education were 74% less likely (AOR 0.30 95% CI 0.15-0.58 p -< 0.001) odds of ARI. Children who were underweight had 1.50 times the odds of ARI compared to those who were not (AOR 1.50 95% CI 1.28 -1.68 p -< 0.001). Using charcoal for cooking was associated with 2.67 times increased odds of ARI (AOR 2.67 95% CI 2.09-3.4 p-<0.001) as compared to using electricity  , 22, 23 et al. 2015, showed that vitamin A deficiency was associated with increased susceptibility to infection due to the changes that occur in the epithelial tissue of the lung tissue [This finding is related to the low immunity of underweight children which increases their vulnerability to developing infections including acute respiratory infections . Childreg tissue . Our stug tissue , 28. Thig tissue . Among vg tissue , 30.A number of studies conducted in various parts of Ethiopia have also shown increased risk for ARI among children from homes which use unclean cooking fuel such as charcoal and firewood , 21. StuA downward trend has been observed in the prevalence of ARI among under five children in Zambia. Young age, being underweight, use of cooking fuels such as wood and charcoal have been associated with increased risk for ARI. Having vitamin A supplementation, maternal education and have been found to be protective against ARI among children. There is need to introduce/scale up nutrition programs focusing on reducing malnutrition among under five children and introduction of health promotion programs to address overcrowding and use of unclean cooking fuels such as charcoal and firewood.The prevalence of ARI among under five children in Zambia;The predisposing factors to ARI at global level and strategies to end child death due to pneumonia and diarrhoea.The trends of ARI among children in Zambia;Using nationally representative data factors associated with ARI among under five children are identified and include biomass fuel and poor nutrition which are more common in the rural areas;Micronutrient supplementation such as vitamin A has been found to be protective hence it should be emphasized at all levels of healthcare.


Apart from few small single-center studies, there are limited data about STEMI patients in Egypt. Nineteen Egyptian centers (with and without PCI facilities) participated in this registry with 1356 patients who were compared to 7420 patients from other ESC countries. The aims of this study were to describe the characteristics of patients with STEMI, to assess STEMI management patterns particularly the current use of reperfusion therapies, to evaluate the organization of STEMI networks across Egypt, to evaluate in-hospital patient outcome, and to compare Egyptian patients with other ESC countries.p < 0.001 and 4.36% vs. 19.41%% were ≥ 75 years old; p < 0.001) with fewer females . Egypt had longer median time between symptoms onset and first medical contact: 120.0  vs.100.0  p < 0.001. Self-presentation rather than EMS presentation was the mode of admission in 86.06% in Egypt vs. 25.83% in EU countries (p < 0.001). On qualifying ECG, anterior STEMI was in 57.08% in Egypt vs. 45.98% in other countries (p < 0.001). Initial reperfusion therapy was 49.12%, 43.07%, and 7.26% for primary PCI, thrombolytic therapy and no reperfusion in Egypt vs. 85.42%, 7.26%, and 7.82% for EU countries, respectively. In-hospital mortality was 4.65% in Egypt vs. 3.50% in other countries p 0.040 and was 18.87% in no reperfusion vs. 2.10% in primary PCI vs. 4.97% in thrombolysis (p < 0.001) among Egyptians. Patients were discharged on aspirin in 98.61%, clopidogrel in 91.07%, ticagrelor in 7.31%, DAPT in 97.69%, beta blockers in 82.83%, ACE inhibitors in 84.76%, MRAs in 10.01%, and statins in 99.77%.Compared to other ESC countries, Egyptian patients were younger (mean age 55.4 ± 11.3 vs. 62.9 ± 12.4; Compared to other ESC countries, Egyptian STEMI patients were younger, more frequently current smokers and diabetics, and had longer time between symptoms onset and first medical contact with more self-presentation rather than EMS presentation. Thrombolytic therapy is still a common reperfusion therapy in Egypt while primary PCI was offered to half of the patients. In-hospital mortality was significantly higher in Egypt and was highest among no reperfusion patients and lowest among PPCI patients. Mortality due to CVD in Egypt is one of the highest compared to other countries in the region and worldwide .Apart from a small number of single center studies there are limited descriptive data about STEMI patients in Egypt –4. The lThe European Society of Cardiology ACCA-EAPCI Registry on ST elevation myocardial infarction is a Joint initiative of the Acute Cardiovascular Care Association (ACCA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology. It is a registry to evaluate the treatment of STEMI across Europe and the Mediterranean countries. It is a general, prospective, multicenter, and observational registry. The ESC-STEMI registry study design has been described in detail in a recent publication .The EURObservational Research Programme (EORP) department at the European Heart House coordinated the project operationally, provided support to the participating centers, and guided the methodological aspects of the survey. The database was stored and analyzed at the European Heart House.The Egyptian society of cardiology, being a member of the ESC, participated in this registry with data from 19 Egyptian centers. Site selection aimed at centers of different levels of complexity and in different geographic regions in order to obtain a sample representative of Egyptian population. Onsite PCI capability was present in 15/17 centers (88.24%), onsite cardiac surgery in 11/17 centers (64.71%), and 8/16 (50.00%) reported that primary PCI was their usual treatment for STEMI patients. The median number  of beds in these centers was 91.5 , MI volume/year was 500.0 , total PCI/year was 800.0 , and total primary PCI was 220.0 . Local audits were performed in randomly selected centers to check compliance with the protocol and review consecutiveness and quality of data.The target population was patients with chest pain or equivalent symptoms of more than 20 min duration within the last 24 h prior to admission to hospital and ST segment elevations or LBBB in the diagnostic ECG. Each center was asked to enroll up to 60 consecutive patients. Egypt participated with 1356 (15.45%) patients who will be compared with 7420 patients from other EU or Mediterranean countries. Patient recruitment started from March 2016 to February 2018.The aims of this study were to describe the demographic, clinical, and biological characteristics of patients with STEMI admitted to a representative setting of cardiology centers in EGYPT, to assess the organization of STEMI management across Egypt, to evaluate how STEMI ESC guidelines were adopted, to evaluate in-hospital patient outcome, and to compare Egyptian patients with those from other participating countries.χ2 test. Continuous variables were compared by the Mann–Whitney U test. Kruskal–Wallis test was used when more than two groups were compared. A p value of < 0.05 was considered statistically significant. All tests were two-sided.Continuous variables were reported in means (standard deviation) or as median and interquartile range (IQR) when skewed. Categorical variables were reported as percentages and compared using the p value < 0.001 and patients ≥ 75 years old were 4.36% vs. 19.41%; p value < 0.001) with fewer females . Furthermore, fewer Egyptian patients had history of myocardial infarction , chronic heart failure , Stroke/TIA , PCI , CABG , atrial fibrillation , peripheral vascular disease , and malignancy  but no significant difference for patients on dialysis . On the other hand, Egyptian patients had higher prevalence of traditional risk factors such as current smoking , diabetes mellitus , BMI ≥ 30 kg/m , LDL cholesterol (mg/dL) , plasma glucose (mg/dL)  but less history of hypertension Compared to other countries, Egyptian patients were younger  while the median time between symptoms onset and first medical contact was 120.0  vs.100.0  . In Egypt, compared to other countries, ER staff was the first medical contact , self-presentation was the mode of admission  and a non PCI capable center was the first hospital receiving STEMI patients Median time  in minutes between symptoms onset and call for medical help in Egypt was 85.0  vs. 74.5  in other countries , atrial fibrillation was in 3.47% vs. 6.20% , and heart rate (mean ± SD) was 84.8 ± 19.4 vs. 78.4 ± 19.6 . Killip class IV was in 2.88% in Egypt vs. 4.27% in other countries , mechanical ventilation was used in 4.06% in Egypt vs. 5.67% in other countries , therapeutic hypothermia was used in 1.40% in Egypt vs. 2.14% in other countries , and therapeutic hypothermia when used was external cooling pads/blankets/wraps in 100.00% in Egypt vs. 11.41% in other countries .Patients admitted after an out of hospital cardiac arrest in Egypt was 2.51% vs. 5.49% in EU countries Intended treatment for STEMI in Egypt vs. other countries was primary PCI in 50.59% vs. 85.50%, thrombolysis in 43.14% vs. 5.55%, and no reperfusion in 6.05% vs. 4.72%. Actual initial reperfusion in Egypt vs. other countries: primary PCI in 49.12% vs.85.42%, thrombolytic therapy 43.07% vs.7.26% and no reperfusion in 7.82% vs.7.32%. Thrombolysis was given in the CCU/ICU rather than EMS or ER in 97.26% in Egypt vs.43.77% in other countries.Intended treatment for STEMI in Egypt vs. other countries was primary PCI in 50.59% vs. 85.50%, thrombolysis in 43.14% vs. 5.55%, and no reperfusion in 6.05% vs. 4.72%. Actual initial reperfusion in Egypt vs. other countries: primary PCI in 49.12% vs. 85.42%, thrombolytic therapy 43.07% vs.7.26% and no reperfusion in 7.32% vs.7.82%. Thrombolysis was given in the CCU/ICU rather than EMS or ER in 97.26% in Egypt vs. 43.77% in other countries.p value < 0.001), heart failure ; Killip class IV , atrial fibrillation ; and no difference in mechanical complications . On the other hand, primary PCI had higher definite stent thrombosis (1.36% vs. 0.00%) and most serious bleeding .Compared to thrombolytic therapy, patients who were treated with primary PCI had less incidence of cerebrovascular accident  but less re-infarction , stent thrombosis , atrial fibrillation , and higher LVEF before discharge 50.4 ± 9.6 vs. 47.4 ± 10.4; p value < 0.001.Compared to other countries, STEMI Egyptian patients had more cerebrovascular accident : 18.87% in no-reperfusion Egyptian patients, 2.10% in primary PCI, 4.97% in thrombolysis . Time between symptoms onset and death (minutes) was 2517.6 ± 3477.2 in Egypt : 1889.5 (± 2803.3) in no-reperfusion, 3701.3 ± 5403.6 in primary PCI, 2379.3 ± 2623.3 in thrombolysis; p = 0.532. Time between first medical contact and death (min) mean ± SD was 2301.7 ± 3461.0 in Egypt : 1652.5 ± 2867.7 in no-reperfusion, 3477.0 ± 5303.9 in primary PCI, 2182.1 ± 2622.3 in thrombolysis. Time between arrival at hospital and death or discharge (days) Mean ± SD was 3.6 ± 8.9 in Egypt : 2.9 ± 2.1 in no-reperfusion, 3.8 ± 12.5 in primary PCI, 3.4 ± 1.8 in thrombolysis, p value < 0.001. Percent of patients transferred to other hospitals if discharged alive was 47/1293 (3.63%) in Egypt vs. 1069/7026 (15.21%) in other countries p value < 0.001.In-hospital mortality was 4.65% in Egypt , statins in 99.77%, beta blockers in 82.83%, ACE inhibitors in 84.76%, ARBs in 3.31%, MRAs in 10.01%, digoxin in 0.85%, ivabradine in 6.62%, ezetimibe in 1.92%, and PPIs in 48.96%.Egyptian STEMI patients were younger than their counterparts in other countries. This observation has been reported repeatedly in many previous Egyptian studies . This miThe higher prevalence of traditional risk factors among Egyptian patients highlights the importance of focusing on primary prevention which is as important as treating patients with acute cardiovascular events. Egypt needs a national primary prevention strategic plan to early detect and properly control these risk factors.EMS service is very much under used among Egyptian patients with STEMI. This very low rate of EMS usage among STEMI patients is similar to the lowest rate among European countries which, in one report, ranged from 18 to 85% [In this registry, all indicators of out of hospital delay, like the median time between symptoms onset and call for medical help and the median time between symptoms onset and first medical contact, were significantly longer among Egyptian patients. Self-presentation rather than EMS-presentation, having hospital ER rather than the ambulance as the first medical contact, and presenting to a non-PCI capable hospital were potential causes for pre-hospital delay in Egypt .In this registry, the median time in minutes between symptoms onset and call for medical help in Egypt was 85.0 vs. 74.5 in EU countries, while the median time between symptoms onset and first medical contact was 120 vs.100 min. Among patients treated with primary PCI, the median time from symptom onset to first medical contact ranged from 60 to 210 min, the time between FMC to balloon ranged from 60 to 177 min while the total ischemic time ranged from 180 to 325 min.In an older European report, among patients treated with thrombolytic therapy, the median time from symptom onset to first medical contact ranged from 68 to 210 min, the time between FMC to thrombolytic therapy ranged from 30 to 110 min while the total ischemic time ranged from 113 to 320 min.In an Egyptian registry, among 137 STEMI patients treated with primary PCI in a single tertiary center, the mean time of pain to FMC was 378 min while the door to balloon time was 41 min .Many reports from both developed and developing countries have shown marked improvement (reduction) of total ischemic time and prehospital time delay after adopting national plans to increase patient awareness and to connect cardiac centers and EMS via regional networks –14.The lower incidence of out of hospital cardiac arrest in Egypt might be due to either under reporting because of culture issues in Egypt to avoid post mortem investigation and the very low rate of EMS use or a true lower incidence due to younger age and lower risk profile of the Egyptian patients.In Egypt, therapeutic hypothermia is not a well-established used technique among post-cardiac arrest patients and hypothermia when used was only external cooling pads, blankets, or wraps.Atrial fibrillation and heart failure were lower among Egyptian patients probably due to the younger age or to under-diagnosisThe practice of primary PCI in Egypt has improved along the past decade despite a lot of obstacles mainly limited public medical insurance coverage and limited number of 24/7 cath labs with well trained staff especially in remote Egyptian areas. In a registry of the largest two cardiology centers in Egypt, from 2007 to 2011, only 7.2% of PCI procedures were for non-elective patients with STEMI and NSTEM .In the Egyptian National heart Institute Registry, among patients with ST-elevation, 65.5% received streptokinase while only 12.4% were referred for primary PCI . In a moThe ACCESS registry, a prospective observational multinational registry, 134 sites in 19 countries in Latin America, middle east, north, and south Africa, 9732 ACS patients with 1 year follow-up, 45% STEMI and 52% NSTEMI, STEMI had fibrinolysis in 30% and primary PCI in 26% .Among 20 European countries, there was large difference in the rate and pattern of STEMI reperfusion: primary PCI ranged from 5 to 92%, thrombolysis ranged from 1 to 55%, and no-reperfusion ranged from 7 to 52% in some countries. Egypt was not included in that report.In a more recent report, the rate of primary PCI per 1 million inhabitants ranged from 25 to 884. The recommended figure is > 600 PPCI per 1 million inhabitants; for Egypt it was 29 per 1 million inhabitants. Egypt short-term target should be 400 PPCI per million, i.e., total of 40000 PPCI/year, i.e., 40% of the estimated total number of 100,000 STEMI/year , 19.According to a recent report, Egypt has < 10 interventional cardiologist/million inhabitants compared to Germany which has ≥ 25, < 2 cath labs/million vs. ≥ 5 in Germany, and < 1 PPCI cath lab/million vs. ≥ 4 in Germany. The number of PPCI procedures was < 200 per million compared to ≥ 600 in Germany [Non-reperfused patients are mainly those with late presentation beyond the window of reperfusion. Their number was probably under estimated because we included 19 very active centers that apply guidelines recommendations in the diagnosis and management of STEMI patients.Thrombolysis is still a very common reperfusion method among STEMI patients in Egypt and is mostly given in the ICU/CCU of the hospitals and almost never in the EMS  nor in the ER. The thrombolytic agent given is mostly streptokinase and not TNK or rTPA due to limited resources. Routinely sending patients post thrombolysis to primary PCI within 2–24 h is generally underused strategy. Egypt should improve all aspects of this mode of reperfusion when applied.The highest incidence of complications was among the non-perfused patients, who had the highest incidence of in-hospital mortality compared to re-perfused patients.Primary PCI patients had fewer incidences of cerebrovascular accidents heart failure and atrial fibrillation probably due to higher incidence of successful reperfusion while they had higher incidence of serious bleeding (probably related to vascular access site bleeding) and stent thrombosis obviously as stenting is their default treatment.The higher incidence of cerebrovascular accidents among Egyptian Compared to EU patients is probably due to higher use of thrombolytic therapy among the former. The lower incidence of re-infarction, stent thrombosis, AF, and Heart failure among Egyptian patients might be underestimated or due to younger and less risk profile of these patientsThe statistically significant higher in-hospital mortality among Egyptian patients despite their younger age and lower risk profile (4.65% vs. 3.50%) is probably due to the lower rate of primary PCI for reperfusion, the longer delay before first medical contact and the less application of advanced techniques like LV assisting devices and hypothermia.In an older report, the in-hospital mortality in STEMI patients in different European countries ranged from 3 to 13%. In an American report, the in-hospital mortality for STEMI patients treated with PPCI varied between 3.1 and 6.1%. Egypt is to be compared to the lower range of these old reports, but mortality rate has already improved in these countries.The mortality rate among Egyptian primary PCI patients reported in this registry (2.10%) indicates improvement compared to an older study  in which the in-hospital mortality rate among 137 patients treated with primary PCI in one Egyptian tertiary center was 6.57%.The highest rate of in-hospital mortality among the group of no-reperfusion (18.87%) indicates that we should encourage their earlier presentation because late presentation was the main cause of not offering them any kind of reperfusion.Clopidogrel is the most commonly used ADP receptor blocker even among STEMI patients (91.07%) while ticagrelor or prasugrel were only used in 7.31% of Egyptian patients. This might be due either to financial reasons where clopidogrel is available in generic forms, the higher rate of thrombolytic therapy usage where clopidogrel is the default drug, concerns about risk of bleeding or just practice inertia. More potent antiplatelets should be the default drugs used in STEMI patients according to the guidelines .Statins are prescribed for most STEMI patients at discharge (99.77%), but we do not know which doses are prescribed for such high risk patients. We lack long-term follow-up studies to document the rate of patients’ compliance and adherence.Total ischemic time is much increased due to both patients and system delays. There is an urgent need for public awareness and patient education campaigns to instruct patients with chest pain to seek medical advice as early as possible together with improving the EMS performance in Egypt. The vast majority of patients with STEMI in Egypt have been self-presented to hospitals rather than via EMS system. We need to improve the performance of EMS in Egypt to become a dependable and efficient mode of STEMI patients transfer.The number of primary PCI/ per million populations is small due to the limited number of primary PCI centers which, when present, is not connected to a regional network of referring hospitals. There is an obvious unmet need to develop such hub and spoke system in Egypt especially in remote and rural areas. The government should extend the umbrella of medical insurance and its reimbursement to health care centers providing emergency STEMI reperfusion –24.One of the main obstacles that prevent big hospitals at some times to admit patients with STEMI is the lack of empty beds in the CCU. A solution to this problem is patient repatriation after the primary PCI procedure to the local referring hospital. In our study, there was a lower incidence of patients discharged to another hospital, compared to European countries, which is due to absence of repatriation policy.Pharmaco invasive approach might be a practical way of treating STEMI patients in remote and rural areas, in major cities with heavy traffic and in areas with inefficient EMS system. Thrombolytic agent should be the TNK and not the streptokinase and better given before reaching hospital. Routine coronary angiography with possible PCI to the infarct related artery within 2–24 h after thrombolytic therapy is a guidelines class IA recommendation but in Egypt it is often either neglected or performed after the recommended time window. Such procedure is not reimbursed by the government assuming that the patient has been already reperfused by the thrombolytic therapy –29.Despite every effort to include many centers with diverse activities and geographic locations these centers, and these patients might not represent the actual Egyptian practice especially in some remote and rural areas in Egypt.Compared to EU countries, Egyptian STEMI patients were younger, more frequently current smokers and diabetics, and had longer time between symptoms onset and first medical contact with more self-presentation rather than EMS presentation. Thrombolytic therapy is still a common reperfusion therapy in Egypt while primary PCI was offered to half of the patients. In-hospital mortality was significantly higher in Egypt and was highest among no reperfusion patients and lowest among PPCI patients. DAPT and statins at discharge were adequately following guideline recommendations.