Circulating cell-free DNA (CFD) was found to be a predictor of outcome in severe sepsis and septic shock . The staSeventy-six patients diagnosed with severe sepsis hospitalized in the ICU were enrolled in the study. Serum CFD levels were measured upon admission and after 72 hours using the SYBR-Gold rapid direct fluorescent assay [P = 0.140). Similarly their admission CFD levels were higher than in survivors . Spearman's correlation analysis showed significant correlation between APACHE II score and CFD level on admission . ROC curve for APACHE II score and CFD level on admission for prediction of 28-day mortality showed area under the curve of 0.59, 95% CI 0.44 to 0.74 (P = 0.208), for APACHE II score; and area under the curve of 0.73, 95% CI 0.60 to 0.86 (P = 0.001), for CFD level on admission. The study group was divided into quintiles by CFD levels of admission. The 28-day mortality rate was 12.5% in the CFD lowest quintile and 60.9% in the highest quintile. Logistic regression analysis showed that adjusted for age, sex and APACHE II score CFD divided into quintiles was significantly associated with death at 28 days, OR = 1.83 per quintile .Out of those diagnosed with severe sepsis, 28 (36.8%) have died either during hospitalization or within 28 days of admission to the ICU. Decedents had higher APACHE II score on admission (median 24.5 vs. 17.5, By using a simple fluorometric assay, we were able to measure CFD levels in severe septic patients. CFD levels were found to be an independent predictors for 28-day mortality. We believe that CFD is an objective, reliable and integrative prognostic marker that will allow fast evaluation of intensive care patients and predicting mortality.


Echinococcus. Iran is known as endemic region for this infection in the world. Vaccination has been considered as a good prevention method for this disease. Recombinant vaccines containing EG95 protein, against E. granulosus, has shown a high degree of protection against E. granulosus infection. In this study EG95 gene was extracted from Iranian isolates of E. granulosus and then cloned and expressed in expression vector.Echinococcosis or hydatidosis is a chronic, zoonotic worldwide infection that occurs by the larval stages of taeniid cestodes of the genus Protoscoleces were collected from sheep hydatid cysts. Then DNA and RNA were extracted from protoscoleces, and amplified by PCR and RT-PCR with specific primer. Afterward the purified RT-PCR products were successfully ligated into pTZ57R/T plasmid vector. The pcDNA3 plasmid was used as expression vector and Eg95 fragment sub cloned into this plasmid. The pcEG95 plasmid was digested by restriction enzymes to confirm cloning of this gene in pcDNA3 plasmid. In last step, the subcloned gene was expressed in CHO as eukaryotic cell.EG95 fragment successfully was subcloned in pcDNA3 and EG95 protein was expressed by eukaryotic cell. The recombinant EG95 protein was confirmed by SDS-PAGE and Western blot.Recombinant plasmid of pcEG95 was constructed successfully and express of recombinant EG95 protein was confirmed. Echinococcus  . In othe(96–98%) .E. granulosus and cloning as well as expressing it in appropriate expression vector.Since, there was no study in Iran regarding the gene coding EG95 protein production, so we investigated to extract EG95 gene from Iranian isolates of Sheep hydatid cysts were collected from a slaughterhouse in Sari City, Mazandaran Province, Iran, where the incidence of the infection is high. Protoscoleces were aspirated from cysts, pooled, and washed with sterile PBS.DNA was extracted from protoscoleces by phenol-chloroform method . The DNA®) according to the manufacturer's instructions. The RNA concentration and quality was assessed by both UV absorbance and electrophoresis on the 1.5% agarose gel.The protoscoleces immediately after washing with PBS, was placed at the liquid nitrogen over night. Then total RNA extracted from protoscoleces with the RNX Plus kit . Primers were designed according to the published E. granulosus EG95 vaccine antigen (EG95) cDNA sequences (GenBank accession number AY421719.1). The forward primer: CGGAATCATGGCATTCCAGTTATGTCTC, with the restriction site for EcoRI, and Reverse primer: GCCTCGAGTCAAGTAAGGACAAC, with the restriction site for XhoI. PCR procedure including initial denaturation at 94°C for 4 min, then 35 cycles of denaturation at 94°C for 1 min, annealing at 53°C for 1 min, extension 72°C for 1 min, and final extension at 72°C for 10 min. The PCR product was analyzed by electrophoresis on a 1.2% agarose gel and the size of them compared with 100 bp DNA ladder . This amplified DNA was sequenced with Capillary Electrophoresis System by Macrogen Company (Korea).The EG95 gene of ®), then this cDNA was used as template DNA for RT-PCR amplification. The primers used in this reaction, was the same as the primers used in PCR reaction. RT-PCR procedure included initial denaturation at 94°C for 3 min, then 35 cycles of denaturation at 94°C for 1 min, annealing at 53°C for 40 sec, extension 72°C for 45 sec, and final extension at 72°C for 10 min. The RT-PCR product likewise the PCR product was analyzed by electrophoresis on a 1.5% agarose gel and the size of them compared with 100 bp DNA ladder, then this products were isolated and purified from agarose gel with using DNA gel Extraction Kit .The total RNA reverse was transcribed to cDNA  according to the manufacturer's instructions. For predispose the bacteria, we used E. coli Top10 strain and calcium chloride method (®), and digested by EcoRI and XhoI enzymes. The enzymatic reaction was performed in two conditions, mono and double digestion, separately. The products was analyzed by electrophoresis on a 1% agarose gel and the size of them compared with 1kb DNA ladder . Eg95 gene that digested from pT-Eg95 in double digest reaction, extracted from gel by using gel Extraction Kit .The purified RT-PCR products were ligated into pTZ57R/T plasmid vector . The Eg95 fragment was ligated into the digested pcDNA3 according to the same protocol that used for ligation of Eg95 and pTZ57R/T . Then digested plasmids were purified from agarose gel by using DNA Extraction Kit (AccuPreppTZ57R/T . The ligprotocol  and cultpcEG95-IR was transfected into the Chinese hamster ovary cell (CHO) using Fugene 6 Transfection reagent kit (Roche). Transfected cells were seeded in a 12-well tissue culture dish with Dulbecco's Modified Eagle Medium (DMEM) contining neomycin antibiotic (G418) and then kept at 37°C in a 5% CO2 incubator.After 14 days, the transfected cell harvested from the media and expressed recombinant EG95 protein was examined on 15% acrylamide gel in SDS PAGE. The resulted proteins were transferred to the nitrocellulose membrane. The membranes were incubated in PBS  and then washed three times with PBST (PBS-Tween20 0.5%.). The nitrocellulose membrane was reacted with 1:200 seropositive mouse antibody for 1 h at 37°C. Then were washed three times with PBST and subsequently treated with horseradish peroxidase (HRP) conjugated with goat anti mouse IgG with 1: 5000 dilution for 1 hour at 37°C. The page was visualized for color after development in Di Amino Benzidine/H2O2 substrate solution for 15 min at room temperature. The reaction was stopped by washing four times in distilled H2O.E.coli. To confirm the ligation, the pTZ57R/T plasmid was digested with EcoRI and XhoI restriction enzymes  were used as templates in PCR and RT-PCR reactions. The result is shown in  enzymes .E. coli. The pcEG95 plasmid was digested by restriction enzymes to confirm ligation of this gene into pcDNA3 plasmid  and transformed into Top10 strain of  plasmid .JF357600.1, JF829212). These sequences were compared with EG95 gene of E. granulosus in GenBank. The result showed 100% homology with E. granulosus EG95-5 and EG95-6 genes, which recorded in GenBank with the AF199350.1 and AF199347.1 accession numbers. In addition, DNA sequence was identical 99% with some sequences recorded in GenBank like AF199349.1, EU595909.1 and EU595882.1.In next step, pcEG95-IR plasmid and amplified DNA of EG95 were sequenced, and the sequences were submitted in GenBank with two-accession numbers   . Controleniidae) . So, useE.granulosus had been performed by Gemmell (1966), where he used oncosphere of the parasite as a crude antigen  only in the oncosphere life-cycle stage, as well as EG95-5 and EG95-6 additionally express in oncosphere, adult worm and protoscoleces , 21.E. granulosus has 492bp and it identical with the sequences reported earlier  reported by Heath and Lawrence .On the other side, a number of studies in mice have shown that DNA vaccination can induce antibody and cell-mediated responses to a variety of bacterial, viral, and parasitic antigens . DNA vacE. granulosus(In the present study, EG95 fragment successfully subcloned in pcDNA3 as eukaryotic expression vector to produce protein for DNA vaccine. Additionally, recombinant plasmid of pcEG95 was constructed successfully to be used for recombinant vaccine. In sheep, vaccination with recombinant EG95 protein induces high levels of protection against anulosus. The mecanulosus.


Background: Evidence on the short-term effects of fine and coarse particles on morbidity in Europe is scarce and inconsistent.Objectives: We aimed to estimate the association between daily concentrations of fine and coarse particles with hospitalizations for cardiovascular and respiratory conditions in eight Southern European cities, within the MED-PARTICLES project.2.5), ≤ 10 μm (PM10), and their difference (PM2.5–10) with daily counts of emergency hospitalizations for cardiovascular and respiratory diseases. We derived pooled estimates from random-effects meta-analysis and evaluated the robustness of results to co-pollutant exposure adjustment and model specification. Pooled concentration–response curves were estimated using a meta-smoothing approach.Methods: City-specific Poisson models were fitted to estimate associations of daily concentrations of particulate matter with aerodynamic diameter ≤ 2.5 μm  were associated with increases in cardiovascular admissions of 0.51% , 0.46% , and 0.53% , respectively. Stronger associations were estimated for respiratory hospitalizations, ranging from 1.15%  for PM10 to 1.36%  for PM2.5 (lag 0–5 days).Results: We found significant associations between all PM fractions and cardiovascular admissions. Increases of 10 μg/m2.5 and PM2.5–10 were positively associated with cardiovascular and respiratory admissions in eight Mediterranean cities. Information on the short-term effects of different PM fractions on morbidity in Southern Europe will be useful to inform European policies on air quality standards.Conclusions: PMhttp://dx.doi.org/10.1289/ehp.1206151Citation: Stafoggia M, Samoli E, Alessandrini E, Cadum E, Ostro B, Berti G, Faustini A, Jacquemin B, Linares C, Pascal M, Randi G, Ranzi A, Stivanello E, Forastiere F, the MED-PARTICLES Study Group. 2013. Short-term associations between fine and coarse particulate matter and hospitalizations in Southern Europe: results from the MED-PARTICLES project. Environ Health Perspect 121:1026–1033;  As part of this process, the EU has indicated several specific issues of concern. Among the open issues is the extent of short-term health effects of fine and coarse particle concentrations and components in Europe, and the shape of the concentration–response relationships between fine particles and mortality and morbidity. Much of the evidence about short-term associations between fine particles  , and ozone (O3) were collected in each city from multiple monitors belonging to air quality monitoring networks. Only monitors with complete data for ≥ 75% of the study period were accepted. When a monitor had a missing value for a specific day, it was replaced by the average of the values of the remaining stations for that day multiplied by a factor equal to the ratio of the annual mean for the missing station over the corresponding annual mean for the other stations  samplers. Daily mean air temperature was collected from each center, using airport meteorological stations where available.stations . When daOther confounders. Time-varying confounders were constructed according to a common protocol, under the assumption of similar behavior of the study populations during holidays and vacation periods. They include holidays ; summer population decrease ; and influenza epidemics . Influenza epidemics were identified using national influenza surveillance systems, where available, or were identified based on daily counts of hospitalizations for influenza .Statistical analysis. The analyses were carried out using a two-stage approach. In the first stage, city-specific overdispersed Poisson regression models were fitted, in which the dependent variable was the daily count of hospitalizations, the exposure was the (lagged) daily concentration of PMx, and variables added for confounding adjustment. The adjustment model was defined a priori and, to reduce the potential for heterogeneity in the city-specific results, was the same for all cities. The confounders were long-term and seasonal time trends, air temperature, holidays, summer population decrease, and influenza epidemics. A directed acyclic graph (DAG) of the causal relationships under study is depicted in Supplemental Material, Figure S1.a) a penalized spline of time trend with 50 knots per year and a smoothing parameter tuned to approximate 8 effective degrees of freedom (df) per year (b) a penalized spline for time trend with the smoothing parameter set to minimize the absolute value of the sum of the partial autocorrelation functions (PACF) of residuals from lag 0 to 30, but requiring a minimum of 3 df per year  a peper year . In bothper year .We controlled for the effect of temperature by modeling high and low temperatures separately. For high temperatures we calculated the average temperature on the current and previous day (lag 0–1) and fit a natural spline with 3 df on the lagged variable only for days on which the lag 0–1 temperature was higher than the median annual temperature for the city as a whole. Similarly, we adjusted for low temperatures by fitting a natural spline with 2 df for the average temperature on previous 6 days (lag 1–6) only for days on which the lag 1–6 temperature was below the median annual value for the city . This mea priori covariates described above. We evaluated the lag structure of the association between PMx concentrations and daily counts of cause-specific hospitalizations by applying cubic polynomial distributed lag models, with individual daily lags from lag 0 to 5 entered simultaneously in the model and constrained to follow a polynomial shape. In addition, we defined three cumulative lag structures a priori to represent immediate (lag 0–1), delayed (lag 2–5), and prolonged (lag 0–5) effects, and chose one of these structures as the default lag for each PM–outcome combination based on the meta-analytical results of the distributed and cumulative lag models. This choice has been applied previously , in addition to year-round data. Finally, we investigated concentration–response functions between PMx and hospitalizations by fitting, for each city, a natural spline model for the exposure with two equally spaced inner knots, and pooling the city-specific estimates using a meta-smoothing approach  of each PM fraction from the joint distribution for the eight cities (six cities for PM2.5–10), and scaled the three resulting IQRs to express PM2.5 effects per 10-μg/m3 increase. In addition, we report selected associations in the text using a common increment of 10 μg/m3 for all three PM fractions.All results are expressed as percent increases in hospitalizations, with 95% CI, relative to fixed increments in each PM fraction: 10 μg/mhttp://R-project.org). Meta-analyses were conducted using Stata, version 11 .All first-stage analyses were fit using R, version 2.15.0  than the others (ranging from 1.5 to 2.2). NO2 and O3 concentrations were similar among the cities, whereas temperature displayed a mild increasing north–south gradient. Pearson correlation coefficients between PM2.5 and PM2.5–10 were close to 0 in Barcelona, Marseille, and Rome (the cities closest to the sea and therefore likely to be more affected by sea winds), but were ≥ 0.5 in the other cities (data not shown). NO2 concentrations were highly correlated with both PM2.5 and PM10 , whereas correlations between NO2 and PM2.5–10 ranged from 0.17 in Marseille to 0.57 in Madrid.Pollutant concentrations and air temperature data for each city are summarized in Supplemental Material, Tables S1 (year-round) and S2 (separate PM concentration distributions for the cold and warm seasons). Daily concentrations of PMPooled estimates from polynomial distributed lag models  clearly show evidence of an immediate effect of the three PM fractions on cardiovascular hospitalizations, up to lag 1, whereas associations with respiratory admissions were evident until day 5.3 in PM2.5, 6.3 μg/m3 in PM2.5–10, and 14.4 μg/m3 in PM10 (lag 0–1) were associated with 0.51% , 0.46% , and 0.53%  increases in cardiovascular admissions, respectively. When expressed per 10 μg/m3, corresponding estimates for PM2.5–10 and PM10 were 0.73%  and 0.36% , suggesting an effect of coarse particles around 40% higher than that of PM2.5 for the same increment. Associations between cardiovascular hospitalizations and PM were null for lag 2–5, and smaller or null for lag 0–5  for a 10-μg/m3 increase in PM2.5, 1.24%  for a 6.3-μg/m3 increase in PM2.5–10, and 1.15%  for a 14.4-μg/m3 increase in PM10. Associations were more homogeneous among cities for lag 0–1, and statistically significant for the coarse fraction  and PM10 . When expressed for increments of 10 μg/m3, the association with respiratory admissions was strongest for coarse particles . We used lag 0–5 for subsequent analyses of association between the PM fractions and respiratory hospitalizations.Associations with respiratory hospitalizations were strongest for all three PM fractions at the cumulative lag 0–5, though the association was not statistically significant for PM2.5–10  but adjusting for PM2.5 decreased the association between cardiovascular hospitalizations and coarse PM . Associations of fine and coarse particles with respiratory admissions (lag 0–5) both decreased considerably with mutual adjustment . Adjustment for NO2 decreased association between PM2.5–10 and both outcomes, whereas it decreased the association between PM2.5 and cardiovascular hospitalizations, but strengthened the association with respiratory admissions. However, given the high correlation between PM2.5 and NO2 in all cities, results from two-pollutant models must be interpreted with caution. No confounding from O3 was apparent in the all-year analysis, nor in the analysis restricted to the warm period. However, associations of PM2.5 and PM2.5–10 with both outcomes were much stronger and always statistically significant when the analyses were restricted to the warm period (April–September) both with and without adjustment for O3.Pooled estimates from one- and two-pollutant models are reported in The robustness of the main findings was checked against model specification in three sensitivity analyses, whose results are summarized in 2.5, PM2.5–10, and PM10 with cardiovascular hospitalizations (lag 0–1) and respiratory hospitalizations (lag 0–5). All estimates are reported as percentage increases in hospital admissions (95% CI) associated with increasing concentrations of PM2.5 and PM2.5–10 relative to 5 μg/m3, and of PM10 relative to 10 μg/m3. Associations of PM2.5 and PM10 with cardiovascular hospitalizations seemed to be consistent with two linear functions, with a steeper slope for lower concentrations. There was no visual evidence of a departure from linearity for PM2.5–10 and cardiovascular hospitalizations, or for any of the PM metrics and respiratory admissions.Finally, We investigated the association between daily concentrations of fine and coarse particles and hospitalizations for cardiorespiratory conditions in eight Mediterranean cities, finding evidence of harmful effects of the PM metrics on both study outcomes.10 as the main exposure . They estimated statistically significant increases in hospitalizations associated with a 10-μg/m3 increase in PM2.5 for a number of specific cardiovascular conditions, ranging from 0.44%  for ischemic heart disease hospitalizations to 1.28%  for heart failure admissions. Positive associations were also reported for hospital admissions for specific respiratory outcomes . Similar results for cardiovascular hospitalizations were reported for another NMMAPS study  in all respiratory admissions associated with 10-μg/m3 increase in lag 2 PM2.5, a weaker association than reported by 2.5 concentrations and components with cause-specific admissions in 26 U.S. communities, and estimated stronger associations with cardiac and respiratory diseases than previous studies: specifically, a 1.89% increase  in cardiac admissions and a 2.07% increase  in respiratory admissions in association with 10-μg/m3 increase in lag 0–1 PM2.5. The authors concluded that “particles originating from industrial combustion processes or traffic may, on average, have greater toxicity.” However, evidence from European studies has been weaker. One six-city study conducted in France , but no associations between PM2.5 and respiratory diseases. Results from single-city European investigations  increase in cardiovascular disease admissions on the same day. However, when adjusted for PM2.5, the association was still positive but no longer statistically significant. Two studies conducted in the United Kingdom (3 increase in lag 0–1 PM2.5–10) and respiratory admissions  with a 6.3-μg/m3 increase in lag 0–5 PM2.5–10). Corresponding associations with a 10-μg/m3 increase in PM2.5–10 were higher than previously reported . However, because PM2.5–10 is obtained as the difference between PM10 and PM2.5, it is affected by measurement error from two sources, and the direction and magnitude of the resulting bias in the associations with hospitalizations cannot be predicted.Epidemiological studies on the short-term effects of PMcounties , a 10-μg Kingdom  did not  Kingdom  found no2.5 and cardiovascular admissions are slightly smaller than those reported by U.S. studies, whereas associations between PM2.5 and respiratory admissions, and associations between both outcomes and PM2.5–10, are more similar. Several differences must be acknowledged between our study and the North American ones. First, the chemical mixture of PM2.5 in Europe is likely to be different from that in the United States. For example, diesel powered cars make up 50% of the fleet in Europe and only about 2% in the United States. Consistent with this, elemental carbon concentrations estimated for 187 counties in the United States were about 0.6 μg/m3 (3 for Madrid and Barcelona (unpublished data). Second, PM concentrations for most U.S. studies were measured every 3rd or 6th day, whereas daily PM measurements were available for the eight cities in the present study. In addition, our study, along with the entire MED-PARTICLES project, comprises Southern European cities characterized by highly urbanized areas with intense traffic congestion, elevated sea traffic due to tourist and shipping activities over the Mediterranean area, mild meteorological conditions favoring outdoor activities during most of the year, enhanced formation of secondary pollutants owing to intense solar radiation, high frequency of wildfires, and Saharan dust advection episodes, especially in summer and spring.Our study is, to our knowledge, the first study involving cities from multiple countries in Southern Europe and investigating the health effects of fine and coarse particles on cause-specific hospitalizations. Our estimates of associations between PM.6 μg/m3  compared2.5 and NO2. The respiratory effects were highly heterogeneous, and there are no simple explanations for that. These heterogeneous effects were already seen in a large Italian study  to adjust for time trends; a penalized spline and a smoothing parameter with 8 df per year; and a penalized spline with df per year selected to minimize PACF residuals . Despite the variation in the degrees of control, the three methods provided consistent results, suggesting little residual confounding due to long-term and seasonal time trends.We estimated much stronger associations of fine and coarse particles with hospitalizations for both cardiovascular and respiratory conditions during the warm period compared with the cold period. This is consistent with the worldwide literature . Two com10 on cause-specific mortality  than higher concentrations, consistent with the dose–response curve previously estimated for the long-term effects of PM2.5 on mortality from ischemic heart disease , non-exhaust emissions, and commercial and industrial residues for coarse particles. Because coarse particles of natural origin cannot be controlled, policy measures aimed at controlling anthropogenic sources of coarse particles would be advisable. Alternatively, a specific short-term limit value for coarse particles (PM2.5–PM10) may be considered, but only in addition to an effective PM2.5 daily limit.We believe that our results have clear implications for the EU policy on air quality. Specifically, they suggest that the current 24-hr daily limit value for PM2.5 concentrations to better target policies on air pollution in Europe.In summary, we estimated significant short-term effects of fine and coarse particles on cardiovascular and respiratory hospitalizations in eight Southern European cities. Associations were similar across PM metrics, stronger but more heterogeneous for respiratory admissions, much more pronounced during the warm period, and robust to time-trend specification. In addition, we did not find strong evidence of departure from linearity in the range of pollutant concentrations measured for the associations under investigation. These findings will help inform planned revisions of EU air quality standards and support legislation on daily PM(627 KB) PDFClick here for additional data file.


Our aim was to estimate the prevalence of distal chronic pain with neuropathic characteristics in patients with type 1 and type 2 diabetes mellitus and its impact on quality of life, mood, anxiety, sleep and healthcare utilization.In total, 885 patients were screened and 766 diabetic patients  were enrolled consecutively over a three-month period in this observational study by 85 diabetes specialists working in a hospital department or in private practice. All the patients completed a series of questionnaires for the detection of chronic pain (i.e. daily pain for more than three months) in the lower limbs and assessment of health-related quality of life , sleep disturbances , depression and anxiety . Patients with chronic pain were also assessed with the 7-item DN4-interview questionnaire, the monofilament test and the Michigan Neuropathy Screening Instrument (MNSI).The overall prevalence of chronic pain with neuropathic characteristics was 20.3% [95% CI 17.4–23.1]. The MNSI examination score suggested that pain was related to polyneuropathy, in 80.1% of these patients . Patients with chronic pain had a poorer quality of life and more sleep disturbances, anxiety and depression than patients without pain and the presence of neuropathic characteristics was predictive of such impairments. Only 38.6% of the patients had received appropriate treatment for neuropathic pain.Chronic pain with neuropathic characteristics concerns one in five diabetic patients, has a significant impact on quality of life and is not adequately managed. The close correlation between the DN4 questionnaire and MNSI results suggests that screening tools for neuropathic pain could be used in daily practice for the identification of painful diabetic polyneuropathy. Sensory distal polyneuropathy is a common complication of diabetes, affecting about 50% of the patients. It may have severe complications, including foot ulcers, amputation and chronic pain Pain associated with diabetic polyneuropathy is, by definition The primary objective of this observational study was to estimate the prevalence of distal (lower limbs) chronic pain with neuropathic characteristics  Ile de France 1, and all patients provided written informed consent before enrollment. Patients were enrolled consecutively over a three-month period (up to 10 patients per center) by diabetes specialists working in a hospital department or in private practice. The inclusion criteria were: patient with type 1 or type 2 diabetes mellitus, over the age of 18 years, with a good understanding of French and with a HbAData were collected through standardized questionnaires. The investigators recorded patients’ demographics, diabetes characteristics, complications, treatments and cardiovascular risk factors. The patients were then asked to report any pain they were suffering in their feet and/or legs and its duration. If the patients reported chronic pain in the lower limbs, defined as daily pain for at least three months, the investigator recorded the treatments for pain received by the patient and administered the DN4 questionnaire, the monofilament test and the MNSI (Michigan Neuropathy Screening Instrument) (see below), before finally noting the cause of pain, according to their own clinical judgment.All the patients (with and without pain) were asked to complete a series of questionnaires to assess health-related quality of life, sleep disturbances and anxiety and depression (see below). The patients with chronic pain, were asked to rate the mean intensity of pain over the previous week on a numerical rating scale , to specify its location, its duration and who they had consulted for this pain.The DN4-interview questionnaire was used to identify neuropathic characteristics of pain. This questionnaire has two questions, comprising seven items: three items relating to pain quality and four items relating to associated paresthesia/dysesthesia. Patients with a score ≥3 were considered to have pain with neuropathic characteristics The 10-g Semmes-Weinstein monofilament test was performed, as described by Perkins et al. The MNSI The assessment of quality of life in patients with and without pain was based on the Medical Outcomes Short Form 12 scale (MOS SF-12) Continuous variables, which had all a normal distribution, are described as means ± SD; categorical variables are expressed as frequency distributions and percentages for the relevant subject groups, with 95% confidence intervals. Missing data were not considered in the expression of the results.Pain intensity scores of 1 to 3 were considered to indicate mild pain, scores of 4 to 6 were considered to indicate moderate pain, and scores of 7 to 10 corresponded to severe pain.1C level, diabetes complications, risk factors) potentially predictive of chronic pain with neuropathic characteristics. The variables significant in the univariate analysis, at a threshold of at least 20%, were entered into a septwise multivariate logistic regression model and the odds ratio for significant factors was calculated with a 95% confidence interval (CI). One-way analyses of variance (ANOVA) were used to compare the scores for quality of life (SF-12), sleep disorders (MOS-Sleep) and mood disorders (HADS) between the various groups of patients. A logistic regression analysis was used to identify the factors  predictive of an altered SF-12, HADS or MOS-Sleep scores. Stepwise logistic regression models were used, as described above, to identify factors independently predictive of alterations of these scores. Data were analyzed with SAS version 9.1 software .A logistic regression model was used to identify the factors  or type 2 (61.2%) diabetes included in the study are summarized in In total, 249 patients reported chronic daily pain for more than three months in the distal lower limbs, giving a prevalence of 32.5% [95% CI 29.2–35.8]. The prevalence of chronic pain was significantly (p<0.01) higher in patients with type 2 diabetes (40.0% [95% CI 35.6–44.4]), than in patients with type 1 diabetes (21.5% [95% CI 16.8–26.2]).The DN4-interview results see  showed tMean pain intensity over the last week was 5.3±2.3 and 76.2% of the patients reported pain of moderate to severe intensity (i.e. NRS score ≥4) . ChronicThe MNSI-examination score obtained suggested the presence of polyneuropathy in 80.1% of the patients with neuropathic characteristics (83.7% of those with type 1 diabetes and 78.8% of those with type 2 diabetes). The proportion of patients with a MNSI-examination score >2 was of 89.5% for patients with bilateral chronic pain. These results, suggesting that distal pain with neuropathic characteristics, particularly when bilateral, is related to polyneuropathy in most patients, were consistent with the investigators’ clinical judgment, with investigators reporting that pain was related to a diabetic polyneuropathy in 91.8% of these patients.By contrast, only 43.2% of the patients with chronic pain with neuropathic characteristics had an MNSI-questionnaire score suggestive of polyneuropathy (i.e. score ≥7/13), and a similar proportion (48.7%) had an abnormal result for the 10-g monofilament test.Nearly 20% of the patients with chronic pain with neuropathic characteristics (n = 31), that is 12.4% of the patients with chronic pain, had no neurological signs according to the results of the MNSI-examination and monofilament test.Univariate analyses showed that several factors, including older age, type 2 diabetes, the presence of other diabetic complications, a history of foot ulceration, higher total and HDL cholesterol levels, higher triglyceride concentration, a history of alcoholism and a higher BMI, were associated with a higher risk of chronic neuropathic pain in the lower limbs see . MultivaPatients with chronic pain had significantly lower physical and mental health subscores for the SF-12, greater impairment of sleep quality and higher anxiety and depression scores see . PatientThe multivariate analyses showed that:1c level ≥7% (OR = 2.01 [95% CI: 1.01–4.02]) and a BMI ≥30 kg/m2 (OR = 2.53 [95% CI: 1.38–5.62]).The independent factors predictive of a lower physical component of quality of life (SF-12 questionnaire) were: being female (OR = 2.33 [95% CI: 1.18–4.56]), a pain intensity>4 (OR = 5.94 [95% CI: 2.43–14.48]), the presence of foot wound/ulceration (OR = 6.76 [95% CI: 2.33–20.48]), a HbAThe independent factors predictive of a lower mental component of quality of life (SF-12 questionnaire) were: being female gender (OR = 2.62 [95% CI: 1.46–4.67]), a DN4 score ≥3 (OR = 3.81 [95% CI: 2.17–6.68]) and a triglyceride concentration >1.6 mmol/l (OR = 2.02 [95% CI: 0.94–4.29]).The independent factors predictive of a lower quality of sleep were: a DN4 score ≥3 (OR = 3.22 [95% CI: 1.71–6.06]), a pain intensity >4 (OR = 4.47 [95% CI: 1.98–10.12]) and an age <49 years (OR = 5.30 [95% CI: 1.90–13.70]).The independent factors predictive of a higher score for anxiety (HADS-A) were: a DN4 score ≥3 (OR = 3.2 [95% CI: 1.72–5.96]), a pain intensity >4 (OR = 2.3 [95% CI: 1.06–4.89]) and a triglyceride concentration >1.6 mmol/L (OR = 3.87 [95% CI: 1.82–8.20]).2 (OR = 1.94 [95% CI: 0.98–3.82]) and a MNSI-questionnaire score ≥7 (OR = 2.20 [95% CI: 1.15–4.13]).The independent factors predictive of a higher score for depression (HADS-D) were: a DN4 score ≥3 (OR = 4.38 [95% CI: 2.27–8.47]), a BMI ≥30 kg/mAbout three quarters (72.7%) of the patients with chronic pain with neuropathic characteristics had previously consulted for their pain. Most had consulted a general practitioner (69.9%) or a diabetologist (65.6%), with smaller proportions consulting a neurologist (26.6%), a rheumatologist (16.8%) or a pain specialist (4.6%).More than two thirds (68.9%) of the patients with neuropathic pain received treatment for their pain. However, only 38.6% of these patients were treated with at least one of the recommended first-line treatment: antiepileptic drugs (24.5%) and/or antidepressants (16.9%).This cross-sectional observational study, the largest to date on this topic to be carried out in France, indicate that one in five diabetic patients suffers daily pain with neuropathic characteristics, in the legs and/or feet, over periods of at least three months. Our data also show that chronic pain with neuropathic characteristics has a major impact on quality of life, mood, anxiety and sleep and that only a minority of patients receive one of the recommended first-line treatments for neuropathic pain. Finally, our finding suggest that screening tools for neuropathic pain such as the DN4 questionnaire, may be of value for the systematic screening of diabetic patients for polyneuropathy.Our overall estimate of the prevalence of distal neuropathic pain in diabetic patients is consistent with previously reported values of the prevalence of painful diabetic polyneuropathy (PDPN), despite the use of different diagnostic criteria in different studies. Three studies carried out in community-based samples in the UK provided estimates of 16.2% In general, our approach, based on validated questionnaires and standardized neurological examination (i.e. MNSI and the monofilament test), was similar to that used in these studies. However, we gave priority to the patients’ symptoms  in our case definition. Neuropathic pain has been shown to have particular clinical characteristics that can be identified with simple, easy-to-use clinical tools based on the analysis of the terms used by the patients to describe their pain (i.e. pain descriptors) A few other epidemiological surveys in diabetic patients have used screening tools for neuropathic pain. Two studies carried out in the Middle East Area and based on the DN4 questionnaire reported higher prevalence rates than in our study. In one study carried out Saudi Arabia The main risk factors for chronic neuropathic pain identified here are similar to those previously reported for painful diabetic neuropathy Relatively few studies have specifically assessed the impact of neuropathic pain on the health-related quality of life (QoL) and psychological comorbid conditions of diabetic patients The unmet needs regarding the management of neuropathic pain, which are not specific to diabetic patients


To the Editor: Noroviruses (NoVs) are the major cause of acute gastroenteritis in children and adults; they are responsible for sporadic cases and outbreaks of gastroenteritis in various epidemiologic settings. NoVs can be classified genetically into at least 5 genogroups, GI to GV  monitors the epidemiology of enteric viruses in children through hospital-based surveillance (www.rivm.nl/mpf/norovirus/typingtool). During November 2011–March 2012, the prevalence of sporadic NoV infections detected  by real-time reverse transcription PCR was 22.2% (121/545). A subset (≈50%) of the NoV-positive samples representative of the whole winter period was selected for sequence analysis, and 48 were successfully characterized in region A and region C. The Italian Study Group for Enteric Viruses  were characterized as the variant GII.4 New Orleans 2009, a smaller number, 6 (12.5%), displayed a New Orleans 2009 polymerase (pol) but 2 distinct GII.4 capsid sequences, which were not typeable in the Norovirus Typing Tool database, and only 2 (4.2%) GII.4 strains of the variant Den Haag 2006b were detected. Moreover, 4 sporadic cases in November 2011 and January 2012 and a small outbreak in February 2012 were related to a GII.Pe_GII.4 recombinant strain. After the set of sequences of GII.4 variants from the Norovirus Typing Tool database was updated , 5 (10.4%) GII.Pe_GII.4 recombinant strains were characterized as variant Sydney 2012.From April through October 2012, a total of 56 (7.6%) NoV-positive samples were detected from 737 analyzed samples, of which 34 (60.7%) NoV-positive samples could be sequenced. Of these, 41.2% were characterized as GII.3 (mostly with a GII.Pb pol), 26.5% as GII.Pg_GII.1, and 17.6% as GII.4 variants. From spring to fall 2012, the variant New Orleans 2009 became the predominant GII.4 strain, and the variant Sydney 2012 strain apparently disappeared. During November–December 2012 and January 2013, ISGEV detected NoV infection in 90 (28.9%) of 311 children hospitalized for gastroenteritis. This finding is comparable to a prevalence of 25.2% in the same period (November–January) of the 2011–12 winter season. A representative subset of 45 samples was randomly selected for sequencing, and 26 (74.3%) of 35 fully typed strains were characterized as GII.4 Sydney 2012, which suggested that the new NoV variant had become the predominant strain in Italy. Our findings seem to mirror observations of a report from Denmark that documented the onset and circulation at low prevalence of the variant GII.4 Sydney 2012 at the beginning of 2012 with a marked increase in the prevalence only by the end of 2012 (Sequence analysis of these early strains of the GII.4 variant Sydney 2012 could help clarify the mechanisms driving its global emergence and spread. Continued surveillance for NoV infections through ISGEV and additional data on clinical and epidemiologic features will enable further assessment of the public health implications of the new variant GII.4 Sydney 2012 in Italy.


To determine the main predictors of all-cause and cardiovascular (CV) mortality in a rural West Indian population in Plymouth, Tobago over 30 years.Questionnaire survey for CV risk factors and alcohol consumption patterns administered at baseline in 1976 with 92.5% response rate. 831/832 patients were followed up until 2005 or death.Hypertension (>140/90 mm Hg) was prevalent in 48% of men and 44% of women, and 21% of men and 17% of women had diabetes. Evidence showed most predictors for all cause and cardiovascular mortality having the main effects at ages <60 years,  but no risk factors having sex-specific effects on mortality. The main predictors of all-cause mortality at age <60 years in the fully adjusted model were high sessional alcohol intake (hazard ratio (HR) 2.04, 95% CI 1.10-3.80), severe hypertension >160/95 mm Hg , diabetes , and BMI . The main predictors of cardiovascular mortality were similar in the fully adjusted model: high sessional alcohol intake (HR 2.47 95% CI 1.10-5.57), severe hypertension (HR 2.78 95% CI 1.56-4.95), diabetes (HR 3.68 95% CI 1.77-7.67) and additionally LVH, (HR 5.54 95% CI 1.38-22.26), however BMI did not show independent effects. For men, high sessional alcohol intake explains 27% of all cause mortality, and 40% of cardiovascular mortality at age <60 yrs. In adults aged <60 years, the attributable risk fraction for IGT/Diabetes and all cause mortality and cardiovascular mortality is 28% in women vs. 11% in men, and 22% in women vs. 6% in men respectively.In this Afro-Caribbean population we found that a major proportion of deaths are attributable to high sessional alcohol intake , diabetes, and hypertension and these risk factors primarily operate in those below 60 years. Tobago is the smaller of the twin island state of Trinidad and Tobago and lies in the South Caribbean just north of Venezuela. A cross-sectional evaluation of the population of Black Rock, Plymouth was conducted in 1976–1978 to evaluate the predictors of all-cause and cardiovascular risk factors and alcohol consumption, and participants followed up until 2005. The total Afro-Caribbean adult population of certified age 20 years and over of a rural village on the north Western coast of the island  was evaluated from 1976–1978. The study comprised 832 participants, 349 (42%) men, and 483 (58%) women, and examined cardiovascular risk factors and alcohol consumption patterns. This village was selected because it was representative of the general population at the time the survey was conducted, had easy access, low migration rates and inhabitants showed willingness to participate in the study.rd participant) 206/483 (43%) of females and 127/349 (36%) of males. The CTR measured was calculated from a vertical line from aorta – widest diameter of heart from the right atrium to centre and left ventricle to centre. Minnesota coding for the ECGs was done by 4 observers trained against the Minnesota standards, and the following ECG categories were defined: major Q waves (codes 1-1 or 1-2), tall left-sided R waves (codes 3-1 or 3-3); S-T depression (codes 4-1 to 4-3), T wave inversion (codes 5-1 to 5-4). Left ventricular hypertrophy/strain pattern was defined as tall R waves plus either S-T depression or T wave inversion. , where p is the prevalence of the risk factor and r is the fully adjusted hazard rate ratio associated with the risk factor where applicable in a specific gender and age-group. All analyses were carried out using Stata version 10.−2) when compared to men (24.1 kg m−2) (P<0.0001).There were 349 (42%) men, and 483 (58%) women. The response rate was 92.5% (832/899). The age distribution of the study population was similar in both sexes; mean [SD] age men 44.1 [17.0] years and mean age for women 43.4 [17.6] years.  Alcohol Impaired glucose tolerance was present in similar frequency in both men and women. Diabetes prevalence was high and comparable between the sexes, 74/349 (21%) in males and 83/483 in females (17%), respectively, p = 0.1. IGT was present in 12% men and 15% women. Mean [SD] blood pressures were similar for males and females: 132 [22] mm Hg in men and 132 [26] mm Hg in women for systolic blood pressure and 86 [13] mm Hg in men and 85 [14] mm Hg in women. Although absolute values for the prevalence of hypertension (>140/90 mmHg) appeared slightly higher in males 167/349 (48%) than observed for females 213/483 (44%), this was not significant p = 0.28). There was no evidence for a difference in prevalence of severe hypertension (>160/95 mmHg) between the sexes , but there was evidence that tall R waves (associated with LVH) were more common in men (34%) than in women (10%) respectively, (p<0.0001). LVH together with strain (Minnesota code 3∶1or 3 and 4∶1-3 or 5∶1-4) was present in 2.6% men and 2.3% women, p = 0.6.At the 30 year follow-up, of the respondents aged less than 60 years at presentation, 203/279 (73%) men and 294/380 (77%) women were still alive, and 76 men and 86 women had died. Of the respondents who were 60 years and over at presentation, 4/70 (6%) men and 15/103 (15%) women were alive, and 66 men and 88 women had died. Cardiovascular deaths accounted for 29/76  and 47/86  in the 20–59 year age group at presentation and 29/66  men and 52/88  in the 60 years and over age group. Cancer caused 49 deaths . There were 102 who died from other causes , and unknown causes of death were recorded for in total 8 study participants  .Univariable analyses of main predictors of death were carried out and are presented in For example, there was strong evidence for effect modification between sex and age on all-cause mortality (p for interaction <0.01), with the hazard ratio (HR) for men versus women being 2.28  1.61-3.22) at ages of 60 years and above, whilst there was no evidence for a difference between men and women for ages <60 years.–2 increase, high sessional alcohol consumption  and alcohol dependence as assessed by CAGE questionnaire score >2 , both adjusted for smoking, systolic and diastolic blood pressure, severe hypertension ≥160/90 mmHg , LV hypertrophy/strain , IGT/diabetes . Serum urate had no discernible effects on all-cause mortality in this younger sample. There was no evidence for an effect of smoking on all-cause mortality. For most of these variables, the univariable associations appeared weaker for those aged over 60 years at baseline.In those aged less than 60 years at baseline, predictors of all-cause mortality in single risk factor analyses (adjusted for age and sex) were BMI with HR 1.04 (95% CI 1.01–1.07) per kg mSubsequent analyses looked at mutually adjusted (multivariable) effects of the significant risk markers on survival . There wIn those aged >60 years at baseline, the main predictor of all-cause mortality in multivariable analyses was the cardiothoracic ratio (HR 1.08 (95% CI 1.02-1.14)).In the multivariable analyses there was statistical evidence for interaction of age-group with systolic blood pressure (p for interaction <0.0001), LVH/strain (p for interaction  = 0.02), and high sessional alcohol intake (p = 0.02), because effects of these variables appeared weaker in those with older age on the multiplicative scale that is underlying a Cox-model. In other words effects of risk factor and age are largely additive. For other variables, which on univariable analyses appeared to have higher point estimates in the older age-group when compared to the younger age-group below 60 years of age there was no evidence to support that the effects were indeed stronger, except for male sex.As seen for all-cause mortality, we found that there was evidence for effects differing by age-group, hence we present the analyses stratified into those <60 and 60+ years of age. −2 increase, high alcohol consumption (adjusted for smoking)  and CAGE questionnaire score >2 with HR adjusted for smoking of 3.16 (95% CI 1.21-8.24), hypertension ≥160/90 mmHg HR 3.06 (95% CI 1.88–4.97), LVH/strain HR 17.14 (95% CI 6.59-44.59), IGT/diabetes HR 1.62 (95% CI 1.01-2.59). There was evidence in the fully adjusted models that high sessional alcohol intake had a weaker multiplicative effect in those aged 60+ years when compared to younger ages  as well as systolic BP  and LVH/strain .In those aged less than 60 years at baseline, predictors of cardiovascular mortality in univariable analyses (adjusted for age and sex) were BMI with HR 1.03 (95% CI 1.00-1.08) per kg mIn those aged 60 years and more, male sex , BMI (HR 1.03 (95% CI 1.00–1.07)), CAGE score >2, adjusted for smoking , hypertension ≥160/95 mmHg (HR 1.62 (95% CI 1.02–2.58)), enlarged CTR  were also associated with increased cardiovascular mortality.In multivariable adjusted analyses, the associations with cardiovascular mortality were generally similar to the adjusted associations observed for all-cause mortality . Older aThe fractions of mortality attributable to hypertension and glucose intolerance were examined in those aged under 60 years at baseline by calculating the attributable risk fractions (ARF) for these two dichotomous risk factors adjusted for all cardiovascular risk factors including smoking for both sexes separately. Because high sessional alcohol intake is a risk factor that is largely prevalent in men, the sex-specific attributable risk fractions are very different, although the association of a given risk factor with mortality was found to be the same for both men and women and only differs by age . For men, high sessional alcohol intake explains 26.5% of deaths of any cause, and 39.9% of cardiovascular deaths at age <60 years, whilst in women the attributable risk fraction for alcohol is negligible. For hypertension, the attributable fractions of mortality from all causes and from cardiovascular disease at the level of 160/95 was more common amongst men  when compared to women  respectively. When fitting sex-specific models, the fractions of all-cause mortality attributable to glucose intolerance or diabetes in those aged <60 years at baseline were higher for all cause mortality in women, 28.3% compared to 10.9% in men. This sex difference was a consequence of the higher hazard rate ratios associated with glucose intolerance in women compared with men because deaths in men were driven by their alcohol intake a risk factor which was largely absent in women. Similarly, for cardiovascular mortality the ARF attributable to IGT/DM was 22.1% for women but and 5.8% for men .We have evaluated the effect of prevalent risk factors on mortality in this population over a 30 year follow-up. We found that excessive sessional alcohol consumption was 10 times higher in men when compared to women and that this explained 40% of cardiovascular deaths of men <60 years. Because high sessional alcohol consumption is very rare in women, the major risk factor in women is impaired glucose tolerance and diabetes, which explained 28% of deaths in women of ages <60 years.Studies in Tobago have identified alcohol as a possible risk factor for cardiovascular disease, attributable to direct effects of alcohol on the heart, but also through effects on blood pressure. (1) A study in Korea found a strong effect of binge-drinking on haemorrhagic stroke in both men and women. A remarkable finding in this study was that in those aged less than 60 years at baseline, there was no sex difference in all-cause mortality rates or cardiovascular mortality rates. Excess mortality in men compared with women was observed only in participants aged 60 years and over at baseline. This contrasts with the experience of developed countries where excess mortality in younger men compared with women is consistently observed in all ethnic groups including African-Americans. The St James Survey Although in those aged below 60 years at baseline, rates of severe hypertension are similar in males (16.9%) and females (16.6%), the ARF for all cause and cardiovascular mortality is over twice as high in males.Mean CT ratios are higher than that of a similar population in Wales, (1) and increased with hypertension. (2) Elevated CT ratio was associated with a greatly increased all cause and cardiovascular mortality particularly in those below 60 years at baseline. ECG findings compatible with ischaemia were uncommon in both sexes. Diabetes was a significant predictor of all cause mortality in the <60 age group (fully adjusted model) HR 3.28 (95% CI 1.89-5.69) but not in the older age group. Results were similar for cardiovascular mortality in the <60 age group HR 3.68 (95% CI 1.77-7.67). Studies in Afro-Caribbeans have also demonstrated increased cardiovascular risk in those with IGT compared to Europeans. Although body mass index was a weak predictor of mortality in those aged less than 60 years this population, both the two main risk factors (hypertension and glucose intolerance) were strongly related to body mass index. BMI was strongly predictive of hypertension, as in other Caribbean populations, A potential limitation of this study is that this was a cohort consisting of a single village in Tobago. However, there was almost complete follow-up on all participants of the original survey. As the cross-sectional study relied on ECG findings and X-ray dimensions and did not store bloods or collect urinary markers, we were unable to perform analyses of more novel cardiovascular risk factors or look at the effects of kidney function or proteinuria on long-term outcome in this population.In summary, in this population, high sessional alcohol intake, glucose intolerance and diabetes, as well as hypertension are the strongest predictors of mortality, particularly in the 20–59 age group. The relationship of obesity to mortality is likely to be underestimated in this study, as independent data on WHR were not available. The high mortality among women is partly explained by glucose intolerance/diabetes and to a lesser degree, the effects of hypertension. The strong association of mortality with ECG evidence of LV hypertrophy/strain is consistent with the importance of hypertension as a risk factor, particularly in those with diabetes or ECG evidence of LV hypertrophy/strain. Data also suggest that individuals with high sessional alcohol intake may have independently increased risk for all cause and cardiovascular mortality, as these associations remain after adjusting for smoking.There are clear public health benefits for modifiable risk factors  for all cause and cardiovascular mortality in this population which may also apply to Afro-Caribbean migrants overseas. This suggests a need for evaluation of different public health intervention programs in this region to address modifiable risk factors to improve the adverse risk profile of this population. It would be useful to explore more sensitive measures of body fat distribution (WHR) and renal function  in relation to long-term all cause and cardiovascular mortality.We have identified in this Afro-Caribbean population that a major proportion of deaths are attributable to high sessional alcohol intake, diabetes, and hypertension and that these risk factors primarily operate in those with younger age. These findings may also have implications for early education and suggested lifestyle modifications for Afro-Caribbeans overseas. Control of obesity would help to reduce the risk of developing diabetes and deliver benefits for those with hypertension, but lifestyle interventions to control obesity, although potentially amenable to public health intervention, are difficult to sustain in the long term.Appendix S1Risk factors for all cause and cardiovascular mortality.(0.05 MB DOC)Click here for additional data file.Appendix S2Attributable Risk Fraction (ARF) for all cause and cardiovascular mortality.(0.04 MB DOC)Click here for additional data file.


Skin disorders are generally considered to be more prevalent in the rural areas of Cameroon. This study was carried out to verify this assumption by describing the spectrum of skin disorders in a rural setting of Cameroon.We carried out a community-based clinical skin examination of 400 consenting subjects from 4 villages of Cameroon: Nyamanga (27%), Yebekolo (24%), Mbangassina (23%) and Bilomo (26%).The overall prevalence of skin diseases in our sample was 62% {95% CI: 57.2%, 66.8%} (248/400). The commonest skin disorders were: fungal infections (25.4%), parasitic infestations (21.4%), atrophic skin disorders (11.7%), hypertrophic skin disorders (9.7%), disorders of skin appendages {acne} (8.9%), benign neoplasm (6.5%), bacterial skin infections (5.2%), pigmentation disorders (4.8%), and dermatitis/eczema (4.0%). Skin infections and infestations constituted 52.82% of all skin disorders. The overall prevalence of infectious and parasitic infestation was 32.75% {95%CI: 28.17%, 37.59%} (131/400) as against 29.25% {95%CI: 24.83%, 33.98%} (117/400) for non-infectious disorders.Among people with skin infections/parasitic infestations, those with fungal infections and onchocercal skin lesions were the most prevalent, accounting for 48.1% (63/131) and 35.1% (46/131); and an overall prevalence of 15.75% {95%CI: 12.3%, 19.7%} (63/400) and 11.5% {95%CI: 8.5%, 15.0%} (46/400) respectively.There was secondary bacterial infection in 12.1% {95%CI: 8.31%, 16.82%} (30/248) of subjects with skin diseases. Hypertrophic and atrophic disorders of the skin were mainly keloids (9.68%), scarification marks (6.05%) and burn scars (5.65%). Skin diseases like dermatitis and eczema (4.03%), malignant tumours and pigmentation disorders were rare in our sample.The proportion of subjects diagnosed with skin disorders after examination (62.8%) was significantly higher than the proportion of 40.8% that declared having skin diseases (p < 0.0001).The prevalence of skin diseases in the rural Mbam valley is alarming, dominated by easily treatable or preventable skin infections and their magnitude is highly neglected by the community, contrasting with findings in the urban setting. Similar studies are needed in other ecological/demographic settings of the country in order to construct a better understanding of the epidemiology of skin disorders. This would lead to the development of national policies to improve skin care. Generally, the information available on the prevalence and incidence of common skin diseases is scarce. This is even more so in Sub-Saharan Africa (SSA). However, since the last WHO 30-year review of epidemiological studies in which only 18 were published on common skin diseases in the developing world [In Cameroon, a recent hospital-based study estimated the prevalence of common skin disorders among patients consulting the dermatology unit of a reference hospital in the capital city of Yaoundé as follows: allergic reactions 34.3%), infections 19.6%), skin appendages disorders (14.6%) and pigmentation disorders (4.3%) to be the most frequent common skin disorders . Althoug4.3%, inf%, skin aSkin disorders have been generally considered to be more prevalent in the rural areas of Cameroon where poor hygienic conditions prevail and access to health care is limited. However, no study has yet been carried out to verify this assertion. We formulated the hypothesis that skin disorders are more frequent in the rural areas of Cameroon than in the urban areas. We therefore carried out this study with the purpose of describing the spectrum of skin disorders in a rural setting of Cameroon.In March 2010, we carried out a community-based cross-sectional survey of skin disorders in 4 rural communities  located some 120 Km north of Yaoundé the capital city of Cameroon. These villages are found in the Mbangassina Subdivision of the Mbam and Kim Division in the northern part of the Central Region. The study site is found in the forest savanna zone with a warm and humid tropical climate and several rivers flow through it  and examination of villagers who came to the community health post in each community.The dermatology team (one senior and two juniors) was assisted by the two medical students for the clinical examination. Each disease registered was classified on the basis of the WHO International Classification of Primary Care (ICPC) . In ordeData was entered using Epi Info version 3.5.1 for Windows and analyzed using SPSS version 15.0. Descriptive statistics including frequency, means, and proportions were used; and the 95% confidence interval was calculated for proportions. The Chi-squared test was used to compare proportions and association between categorical variables. The level of significance was set at a P-value of ≤ 0.05. Results were compared with published data from Yaoundé, the capital city of Cameroon.Ethical clearance (N° 037/CNE/SE/2010) for the survey was obtained from the National Ethics Committee of Cameroon.A total of 512 subjects were invited to take part in the survey and 400 (78.13%) gave their consent. The distribution of the subjects according to the villages was as follows: Nyamanga (27%), Yebekolo (24%), Mbangassina (23%) and Bilomo (26%). The male to female ratio was 1:1. Their ages ranged from 9 to 51 years with a mean age of 21 ± 8.13 years, and there was no age difference between males and females (p = 0.269). The largest proportion of the subjects were in the 20–24 years age group (27.75%) followed by the 15–19 years age group (26.0%). They were mostly farmers (47.25%) or pupils/students (37.5%). Although only 17.25% of the participants were married, 35% had at least 1 child. The majority of the subjects (97.25%) had completed at least the primary level of education, with 33.75% having attained secondary education. Most subjects (99%) were Christians.The details of the skin disorders in our sample are given in Table The skin diseases were slightly more prevalent in males 64.0% {95%CI: 56.93%, 70.65%} 128/200) compared to females 60.0% {95%CI: 52.85%, 66.85%} (120/200) although this difference was not significant (P = 0.4099). Among people with skin infections/parasitic infestations, those with fungal infections and onchocercal skin lesions were the most prevalent, accounting for 48.1% (63/131) and 35.1% (46/131); and an overall prevalence of 15.75% {95%CI: 12.3%, 19.7%} (63/400) and 11.5% {95%CI: 8.5%, 15.0%} (46/400) respectively. There was secondary bacterial infection in 12.1% {95%CI: 8.31%, 16.82%} (30/248) of subjects with skin diseases . Hypertrophic and atrophic disorders of the skin were mainly keloids (9.68%), scarification marks (6.05%) and burn scars (5.65%). Skin diseases like dermatitis and eczema (4.03%), malignant tumours and pigmentation disorders were rare in our sample. Figures /200 compThe distribution of the top 9 skin disease groups in our sample by demographic variables Table  showed tThe proportion of our subjects diagnosed with skin disorders after physical examination (62.8%) was significantly higher than the proportion of 40.8% that declared having skin diseases (p < 0.0001).The present study presents for the first time in Cameroon, to the best of our knowledge, the spectrum of skin diseases in a rural community. The point prevalence of any skin disease of 62% found in the Mbam area is alarming, and validates the hypothesis of a high prevalence of common skin disorders in the rural community of Cameroon. This prevalence lies in the upper half of the range of 21-87% described in SSA  and 53% In the review by WHO children were found to have more skin diseases compared to adults , a findiIn our study, skin infections and infestations were the commonest skin disorders accounting for 52.82%, followed by scars (21.38%), acne 8.87%), other disorders of pigmentation (4.84%) and dermatitis/eczema (4.03%). Although with varying proportions, the spectrum of skin diseases in our study was similar to that described in other community studies in the rural milieu in which skin infections constituted the bulk ,7,9.%, other Superficial fungal dermatitis (25.40%) was the most common skin infection. The predominance of fungal diseases in the category of infections/infestations as shown in Table Onchocercal skin lesions 18.55%) came second among common skin infections/infestations in our sample. This is unusual as bacterial infections or scabies depending on the context are generally the second most common skin infection described in the literature ,4. The M8.55% camOur study demonstrates that common skin diseases constitute a serious cause of morbidity in the Mbam area. This may suggest that the rest of rural Cameroon probably faces the same challenges. This high magnitude of skin disease is grossly under-estimated by the community as only 40.8% of our subjects declared having any common skin disorder compared to the actual finding of 62.8% (p < 0.0001). This situation may be the result of lack of information in the communities on symptoms and eventual complications of common skin diseases. The implication is that some effort still has to be made to improve the level of information in the communities, by organizing sessions of Communication for Behavior Change led by health personnel through the fixed or mobile strategies. These interventions are expected to be effective given that the spectrum of skin disorders found in our study constitutes easily treatable and preventable conditions for the most part.The prevalence of allergic dermatoses which is far below that of infections/infestations in the Mbam area (4.03% versus 52.82%) as in Bamako, Mali (15.5% versus 58.6%) , is striAlthough we know that certain skin conditions are closely associated with HIV infection, this was not the focus of our community-based study. Mbuagbaw and collaborators in a descriptive study reported in an urban setting in Cameroon  that mucThe prevalence of skin diseases in the rural Mbam valley is alarming, dominated by easily treatable or preventable skin infections, contrasting with findings in the urban setting. The magnitude of skin diseases is highly underestimated or neglected by this community. Similar studies are needed in other ecological and demographic settings of the country in order to construct a better understanding of the epidemiology of skin disorders that will lead to the development of national policies to improve skin care.The author(s) declare that they have no competing interests.ACZB and AKN conceived the study; AKN, ACZB, ENT, and WFTM designed the study. JYF, RN, RNN, VS, EK, DD, FD and ACZB collected the data. ENT, ACZB, and AKN analyzed the data and wrote the article. FNY and all authors made critical contributions to improve the scientific content of and approved the final draft of the article.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-5945/12/7/prepub


Objective(s): The present study reports the development and validation of a sensitive and rapid extraction method beside high performance liquid chromatographic method for the determination of crocetin in human serum. Materials and Methods: The HPLC method was carried out by using a C18 reversed-phase column and a mobile phase composed of methanol/water/acetic acid (85:14.5:0.5 v/v/v) at the flow rate of 0.8 ml/min. The UV detector was set at 423 nm and 13-cis retinoic acid was used as the internal standard. Serum samples were pretreated with solid-phase extraction using Bond Elut C18 (200mg) cartridges or with direct precipitation using acetonitrile. Results: The calibration curves were linear over the range of 0.05-1.25 µg/ml for direct precipitation method and 0.5-5 µg/ml for solid-phase extraction. The mean recoveries of crocetin over a concentration range of 0.05-5 µg/ml serum for direct precipitation method and 0.5-5 µg/ml for solid-phase extraction were above 70 % and 60 %, respectively. The intraday coefficients of variation were 0.37- 2.6% for direct precipitation method and 0.64 - 5.43% for solid-phase extraction. The inter day coefficients of variation were 1.69 – 6.03% for direct precipitation method and 5.13-12.74% for solid-phase extraction, respectively. The lower limit of quantiﬁcation for crocetin was 0.05 µg/ml for direct precipitation method and 0.5 µg/ml for solid-phase extraction. Conclusion: The validated direct precipitation method for HPLC satisﬁed all of the criteria that were necessary for a bioanalytical method and could reliably quantitate crocetin in human serum for future clinical pharmacokinetic study. Crocus sativus L., is an expensive spice that is used mainly as a herbal medicine or food coloring and ﬂavoring agent in different parts of the world. Saffron originally grew in Iran, India, Spain, Greece and other countries . Crocin is the principal coloring pigment in saffron stigma. This carotenoid derivative, glycoside derivative of trans-crocetin, is one of the major biologically active components in saffron . Cis-croDifferent experimental studies have demonstrated a variety of pharmacological actions for crocetin such as enhancement of oxygen diffusivity -25, inhiin vitro or in animal samples. The pharmacokinetic of crocetin in rats was reported by Liu and Qian  and 1H and CNMR. Methanol and acetonitrile (HPLC grade) were purchased from Caledon . Acetic acid, ammonium acetate and mono basic sodium phosphate were from Merck . 13-cis retinoic acid, used as the internal standard (IS) (Crocetin was isolated from ard (IS) , was obtHuman serum samplesFive healthy volunteers with normal biochemical parameters were enrolled in this study. These subjects were taken a single oral dose of 16 mg crocetin capsule. Blood sampling was carried out at 0, 20, 40, 60, 90, 120, 150, 180 and 240 min after saffron administration. These human samples were prepared by both direct precipitation and solid phase extraction methods and were analyzed with HPLC method. The human study protocol was approved by local Ethics Committee.Instrumentation and chromatographic condition 18 reversed-phase column  with a Knauer C18 guard column  kept at room temperature. The mobile phase was composed of a mixture of methanol/water/acetic acid (85/14.5/0.5). The mobile phase was ﬁltered through a 0.22 µm membrane ﬁlter and degassed by an ultrasonic bath. The ﬂow rate was 0.8 ml/min and the injections were carried out through a 25 µl loop. The chromatographic system was composed of a Shimadzu  LC-10ADVP chromatographic pump and a Shimadzu UV- SPD-10AVD spectrophotometric detector set at 423 nm. Separations were obtained on a Knauer Chromatography (Germany) C® vacuum manifold system  coupled to the GAST vacuum pump . For extraction procedure, Cronus Bond SPE columns were used. Column size was 3 ml and ﬁlled with 200 mg silica-bond C18 . In order to separate the precipitated proteins, an Abbott D-37520 centrifuge (Germany) at 8500 g and 20°C was used. The clean-up procedure consisted of direct precipitation method or solid phase extraction. Solid phase extraction was performed using WATERSPreparation of standard solutionsStock solutions of crocetin and 13-cis retinoic acid as internal standard were prepared in DMSO in the concentrations of 100 and 50 µg/ml, respectively. Then, the stock solution was further diluted with blank serum and methanol: water (85:15 v/v) separately to give working solutions of 0.025, 0.05, 0.1, 0.25, 0.5, 1, 1.25, 1.75, 2.5 and 5µg/ml of crocetin. All solutions were stored at the freezer temperature (-20ºC).The sample preparation The sample preparation for the procedure was done in two different ways, direct precipitation method and solid phase extraction (SPE).Direct precipitation methodThis method was done according to Xi and colleagues  with somSolid phase extraction (SPE)18 (200 mg) solid phase extraction cartridge , which was washed with methanol (1.0 ml) and equilibrated with water/methanol  containing 0.2% ammonium acetate (2.0 ml) before use. After the sample was loaded, the cartridge was washed with water/methanol  containing 0.2% ammonium acetate (2.0 ml), 0.2% ammonium acetate aqueous solution (2.0 ml) and hexan (2.0 ml), respectively. After that methanol (1.0 ml) was loaded, the eluate was collected. The methanolic eluate was evaporated to dryness under a stream of nitrogen at room temperature. The residue was dissolved in 150 µl water:methanol (1:1 v/v). Then, the mixtures were shaken in the vortex mixer for 1min and centrifuged for 8 min at 8500 g. The obtained supernatant was transferred into chromatographic vials, from where 25 μl of solution was injected into HPLC system for analysis (Serum sample (50 µl) was mixed with 50 µl of 0.1 mol/l sodium phosphate buffer (pH 7.0) and 0.5 ml of methanol containing 13-cis retinoic acid as an internal standard. The mixture was vortexed for 1 min and centrifuged at 8500 g for 10 min. A portion of supernatant (0.4 ml) was mixed with 1.0 ml of 0.2% ammonium acetate aqueous solution. The mixture was then applied to a Bond Elut Canalysis .Method validation Linearity and range Linearity of the analytes was evaluated using freshly prepared samples covering the analysis range. The calibration curve of crocetin was constructed by plotting the peak area ratios of the respective analyte to the internal standard (y) against the analyte concentration (x) (expressed as µg/ ml). The procedure was carried out in triplicate for each concentration. The calibration curve follows the equation of y = bx + a, where b and a refer to the slope and y-intercept, respectively. The analyte concentration, x, was determined from the calibration curve using the formula: x = (y − a)/b  The lowest concentration of the analytes with an accuracy of 80–120%, as well as the coefficient of variation of <20% was regarded as the lowest limit of quantiﬁcation (LLOQ). This concentration was used as the ﬁrst calibration point for the calibration curve.2), and the residuals and coefficient of variation (CV%) to be within ±20% at the lower limit of quantification (LLOQ) and ± 5% for the rest of the concentrations tested. The applied requirements for a valid calibration model were: a regression coefficient higher than 0.990  did not exceed±15%. Intraday precision was evaluated by extracting and analyzing five replicates of a sample within the same run in the same day. This was done in all concentrations. The interday precision was evaluated by analyzing a sample in all concentrations on 5 different days. The requirement for precision was acceptable if the coefficient of variation (CV%) did not exceed±15%, either for intraday or inter days assay. Extraction recoveryThe relative recovery of the samples was determined by the following equation:Relativerecovery=serum crocetin mean peak area ratios/serum 13cis retinoic acid mean peak area ratiosmethanolic crocetin mean peak area ratios/methanolic 13cis retinoic acid mean peak area ratiosResolutions) two components is a measure of how well they are separated. It was defined by the following equation (B was the later eluting peak):The resolution (RRs=2( tR peak A- tR peak B )sum of the peak widths at base in units of timeIn practice, a resolution factor of 1.5 was considered the lowest practical value for quantitative analysis .Symmetry factorPeak symmetry (As) may be calculated by determining the ratio of the distances between the peak maximum and the leading and trailing edges at 10% of peak height. Values of as of between 0.85 and 1.3 were generally acceptable .Figure 3 shows the representative chromatograms of human serum containing crocetin and 13-cis retinoic acid (IS) which extracted with two different methods (direct precipitation or solid phase extraction), obtained from the HPLC-UV system. The retention times for crocetin and 13-cis retinoic acid were respectively 4.125 and 8.775 min after preparation of samples by direct precipitation method whereas these times were shifted to 4.992 and 10.792 min after using the solid phase extraction for preparation of samples. Linearity and range2) were 0.999 and 0.990 for direct precipitation method and solid phase extraction methods, respectively.The calibration curve of crocetin was linear from 0.05 to 1.25 µg/ml serum for direct precipitation method and 0.5 to 5 µg/ml serum for solid phase extraction method. Their regression coefficients (R The LLOQ of crocetin was 0.05 µg/ml serum for direct precipitation method with the coefficient of variation (CV) of 2.6% and 0.5 µg/ ml serum for solid phase extraction method with the coefficient of variation (CV) of 5.34%.SelectivityBoth extraction methods with HPLC used for determining crocetin were found to be selective. No endogenous substances or interfering peaks were observed at the retention time of the crocetin. Figure 4 shows the representative chromatograms of extracted blank human serum containing 13-cis retinoic acid (IS) and the serum extract which contained crocetin and 13-cis retinoic acid (IS) obtained from the HPLC-UV system. Accuracy and precisionThe accuracy of the method with direct precipitation ranged between -9.09 and 2.48 and with solid phase extraction ranged between -23.42 and 10.45. The results are given in Table 1. The intraday coefficient of variations for crocetin in direct precipitation method was less than 3% for all the concentrations and in solid phase extraction method was less than 5.5%, while the interday coefficient of variations for crocetin was less than 6.5% for all the concentrations and in solid phase extraction was less than 12.8% as indicated in Table 2.Extraction recoveryThe mean extraction recovery of the crocetin was somehow good in both methods (direct precipitation 55-88% and solid phase extraction 47-69 %). The data are shown in Table 3.ResolutionThe resolution factors for direct precipitation and solid phase extraction methods were 4.2 and 4.65, respectively.Symmetry factorIn direct precipitation method, the symmetry factors for crocetin and 13-cis retinoic acid were 1.04 and 0.93 while in solid phase extraction method were 0.85 and 0.88, respectively. Human samples Figure 5 shows the concentration of crocetin in human samples in different intervals.As it was mentioned previously, establishment of validated extraction and analysis method for human serum samples is important for clinical pharmacokinetics studies of crocetin. For this reason, in the present study, extraction method beside HPLC method was developed and validated. In this study, 13-cis retinoic acid was used as internal standard. This compound was selected as the internal standard (IS) due to the similarity of its structure to that of the crocetin and its suitable chromatographic properties. According to the International Conference on Harmonization (ICH-1996), the internal standard should be structurally similar to the main compound of analysis . Also, 1 Previously, mixture of methanol:water:acetic acid (75:24.5:0.5) was used as mobile phase  but in t We compared two different extraction methods (Direct precipitation and Solid phase extraction) for detection of crocetin in human serum by HPLC. Comparison of these methods followed by HPLC, the direct precipitation method had higher extraction yields (>70% versus 59%), better sensitivity (LLOQ = 0.05 µg/ml versus 0.5 µg/ ml) and better linearity (0.999 versus 0.990), thus enabling the compounds to be analyzed at very low concentration levels. The differences in LLOQs may be related to the higher drug loss by SPE method compared to direct precipitation method. Direct precipitation method involves one simple step while in SPE method elution and passage of samples through solid phase influence on limit of detection of analysis method.  Accuracy and precision of both methods were found to be within the acceptable range (except the first concentration of solid phase extraction), but direct precipitation showed a better result. The use of direct precipitation method poses several advantages with respect to the solid phase extraction procedures. In fact, the proposed procedure is simple, faster and requires lower volumes of organic solvents. Furthermore, direct precipitation method had a wide linearity range. Also, this method does not involve laborious and time-consuming sample preparation.et al (et al study (et al evaluated the pharmacokinetic profile of crocetin in healthy adult human volunteers and used a solid phase extraction for assays of plasma crocetin but in this study we demonstrated the direct precipitation method was better for analysis of serum crocetin concentration (et al reported mean peak serum concentration 0.2 µg/ml after single oral dose 15 mg crocetin in healthy volunteers (et al reported a SPE method for monitoring crocetin in human plasma ( Previously, high dose of crocetin was used to evaluate the pharmacokinetics of crocetin in animal models. In the study of He et al , 50 mg/kal study , 15 mg/kntration . After alunteers . These cn plasma . This stAnalytical data of the present study can be used to analyse the concentration of crocetin for pharmacokinetics study. The validated direct precipitation method followed by HPLC method satisﬁed all the criteria that were necessary for a bioanalytical method. The presented extraction method was simple and involved only one step.


The administration of 200 mg of RTV to boost TPV plasma levels is associated with poor tolerance and toxicity. Some studies have shown that 100 mg of RTV could be enough to reach plasma levels of TPV that inhibit most HIV strains. This clinical trial was designed to show the efficacy and tolerability of switching to TPV 500/RTV 100 in patients with suppressed viremia receiving TPV 500/RTV 200.Open, randomized, multicenter clinical trial. Pts who were receiving TPV 500/RTV 200 with an HIV RNA<50 copies/mL for at least 6 months and with a genotypic sensitivity score showing activity of TPV were randomized to continue on the same dose or to switch to TPV 500/RTV 100 mg. The efficacy endpoint was the proportion of pts with HIV RNA<50 copies/mL at 48 weeks in an ITT analysis. Discontinuation due to intolerance, liver toxicity and lipid abnormalities were also evaluated. TPV plasma trough levels were measure in all the patients.35 pts were randomized: 16 pts continued on TPV 500/RTV 200 mg while 19 pts were switched to the lower TPV 500/RTV 100 mg dose. At baseline, 48% had AIDS, and mean CD4 count was 515 cells/mm3. Coinfection with HCV was more frequent in pts who continued on the 200 mg RTV group (44%) than in those that switched to the 100 mg RTV group (11%)(p=0.02). Pts had received a median of 10 drugs (including 3.6 PI), and mean duration of TPV therapy was 32 months. Mean number of accompanying drugs was 3.4 in the two groups. Mutations in RT and PRO before initiating therapy with TPV were found in 31% and 20% pts, respectively. After 48 weeks, HIV RNA remained below 50 copies/mL in 89.5% pts in the RTV100 group and in 75% in the RTV200 group . Mean CD4 count change was +24 in the RTV100 group, and -33 in the RTV200 group (p=0.5). A greater decrease in GPT, total cholesterol, and triglycerides was observed in the RTV100 group. One pt on the lower dose developed grade 2 increase in total cholesterol, while 3 pts developed grade 2-4 toxicities in the higher dose group . Median TPV trough levels at 48 weeks were 38854 ng/mL and 25465 ng/mL in the RTV 200 and RTV 100 groups, respectively.Switching from TPV 500/RTV 200 mg to TPV 500/RTV 100 mg in treatment-experienced patients with HIV RNA <50 copies/mL maintains virological suppression, while improving liver and lipid abnormalities.


Candidemia is becoming increasingly widespread, especially in the ICU setup. The Candida score has been developed and used for identifying patients at risk for developing candida infections. However, its usefulness in predicting outcome of patients with candidemia has not been evaluated. We aimed to determine the risk factors for mortality in patients with candidemia admitted to an Indian medical ICU.pro forma. The Candida score was calculated as previously described [An 18-month retrospective cohort analysis including 56 patients with candidemia was conducted. Baseline patient characteristics, ICU course and outcome were noted in a predesigned Candida albicans was isolated in only 21.4% of blood Candida-positive cultures. Among the nonalbicans species C. tropicalis was the commonest species isolated from 28.6% isolates, followed by C. glabrata that was isolated from seven (12.5%) patients. In 8.9% of candidemia patients, the only measure taken was removal of the indwelling catheter, but the rest of the patients required antifungal drugs. Among the patients with candidemia, 53.6% required vasopressor support, 41.1% required renal replacement therapy and 64.3% required mechanical ventilation during their ICU stay. The mean length of ICU stay was 22.9 ± 28 days and the mean hospital stay was 30.1 ± 30.2 days. Crude ICU mortality was 33.93%. There was no statistically significant difference between mortality rates of patients with C. albicans and nonalbicans candidemia (P = 0.732). Patient parameters such as age, admission APACHE II score, candida score, previous antifungals and underlying co-morbidities, which were statistically significant in differentiating survivors and nonsurvivors in the univariate analysis  and Candida score >3  were found to be independently predicting mortality.Out of 3,142 ICU admissions, the incidence of candidemia was 17.8/1,000 admissions. Fifteen patients had co-existing candiduria with the same species. The mean interval between ICU admission and candidemia was 12.9 ± 14.4 days. C. albicans and nonalbicans infection. Patients who develop candidemia, despite being on antifungals, were at a higher risk of dying and a simple bedside candida score may be useful in predicting mortality of ICU patients with candidemia.Candida infection is generally late-onset in ICU patients and is associated with a prolonged ICU and hospital stay, and a high mortality. Candida nonalbicans infection was much more common in our cohort of ICU patients but there was no difference in mortality among patients with


Excessive alcohol consumption is a major challenge to public health. In 2000 it accounted for 4% of the global disease burden. However, the relationship between alcohol and health is complex and the burden it places on admissions to critical care is uncertain.We conducted a retrospective analysis of prospectively collected data on the influence of excess alcohol consumption on the outcome of patients admitted from July 2009 to July 2011. The admitting physician determined the relationship between alcohol use and admission. No patients were excluded. All continuous data are expressed as medians and were compared using the Wilcoxon Mann-Whitney U test. Categorical data were compared using the chi-squared test.P < 0.001). The cases had a lower APACHE II score, 14.3 vs. 15.8 (P = 0.002). Twenty-four (18.6%) of the cases with excess alcohol consumption died on the ICU compared to 141 controls (13.8%) (P > 0.1). The hospital mortality was similar between the two groups, 28 (21.7%) against 215 (21.1%) controls (P > 0.5). The cases spent longer on the ICU, median 3.95 days versus 2.9 in the controls (P < 0.001). On admission the cases required a median of 2.0 organ supportive therapies compared to 1.8 in the control group (P < 0.001). The cases were ventilated for a mean of 4.1 days compared to 2.4 days in the controls (P < 0.001). There was no difference in the rate of sepsis between either group, 10% in the cases and 9.8% in the controls. Twenty-six patients were admitted with known alcoholic cirrhosis (0.23%), 10 with oesophageal varices and three with acute pancreatitis related to alcohol.A total of 1,150 patients were admitted, 129 cases (11.2%) were identified as having excess alcohol consumption. Of these cases 34% were women, whilst 48% of the controls were female. The median age of the cases was 54 years versus 68 years for the controls (To our knowledge this is the largest single-centre assessment of the burden of excess alcohol consumption on patients admitted to critical care. Eleven per cent of all admissions to the ICU were complicated by excess alcohol consumption. The ITU mortality of these patients was increased when compared to the controls, despite the patients having an equivalent APACHE score on admission and tending to be younger. The cases spent less time in hospital than the controls. This was due to a bimodal distribution of their survival curve. Our study is limited by its retrospective design and the risk of selection bias.