The observations presented in this study conclude that the preoperative stimulation with probiotics of the efferent loop through the dysfunctional bowel, to allow the slow infusion, can have a reducing effect on the endoscopic and histopathological alterations of diversion colitis. This procedure may be an alternative treatment to resolve the inflammation in patients where the surgical option is not feasible or available.p < 0.001. The stimulation of the efferent loop of the ileostomy in patients with diversion colitis produced a decrease of the endoscopic and histological severity of colitis in the short term.The use of a loop ileostomy as the defunctioning procedure of choice to protect a distal colonic anastomosis causes histological and endoscopic changes in the intestinal mucosal architecture, which have been related to chronic inflammation and changes in the microflora that consequently impact the intestinal structure and function following fecal stream diversion. The aim of this study was to evaluate the histological and endoscopic changes on the colonic mucosa in patients with diversion colitis after stimulation of the efferent loop with probiotics prior to closure of the protective ileostomy. A prospective, randomized, double-blind, controlled study was designed. All patients who underwent surgery for colorectal carcinoma with protective ileostomy between January 2017 and December 2018 were included. These patients were pending reconstructive surgery and were diagnosed with endoscopic and histological diversion colitis. Divided into two groups, a group stimulated with probiotics (SG) and a control group (CG). 34 cases and 35 controls were included in the study. Histological and endoscopic changes were evaluated after stimulation, after restorative surgery and during the short-term follow-up after surgery. A decrease in endoscopic pathological findings  and in histological findings  was observed in SG. These results were statistically significant with a  Probiotics were defined as live microorganisms that improve the host’s health when administered in adequate amounts ,2. TheseIn patients suffering from colorectal cancer who have undergone partial colonic resection, the creation of a temporary ileostomy causes a defunctionalization of the colon . ConsequDiversion colitis was described by Glotzer et al. in 1981 . It has The endoscopic findings described are: friable mucosa, edema, erythema, appearance of polyps, ulcers, stenosis and histological findings such as lymphoid follicular hyperplasia, infiltration of the lamina propria by lymphocytes, eosinophils, the appearance of plasma cells, architectural disruption, and the appearance of crypt abscesses ,21.The definitive treatment is the restoration of the continuity of the digestive tract ,16. PharProspective, randomized, multicenter, double-blind study, comparing two groups of patients operated for colorectal carcinoma with protective ileostomy. One group includes patients treated with probiotic stimulation of the efferent loop prior to transit reconstruction surgery; the other control group was stimulated without any substance.The sample size was calculated according to the diversion colitis endoscopic and histological findings published in previous studies ,24. AssuBetween January 2017 and December 2018, all the patients, from the three participating centers, that were included in the surgical waiting list for temporary stoma closure (coded according to CIE-10) after colorectal carcinoma, were consecutively evaluated to determine their inclusion in the study. The flowchart for the selection of the study patients is depicted in The inclusion criteria were being over 18 years of age, having protective ileostomy after colorectal carcinoma surgery free of disease, with endoscopic and histological confirmation of diversion colitis and having signed the informed consent. As exclusion criteria: being under 18 years of age, clinical history, and histological confirmation of inflammatory bowel disease with colorectal involvement, and refusal to participate in the study. Abandonment criteria: loss during follow-up, exitus, and anastomotic dehiscence after reconstruction surgery.®® colonoscope . The endoscopic findings were expressed according to the scoring system of Harig et al. [Colonoscopies with random biopsies were performed on all patients to exclude those who did not have colitis and to establish the severity index. Three endoscopists performed the endoscopies with a Silver Scope Storzg et al.  includinBoth endoscopic and histopathological studies were performed after stimulation and 3 months after intestinal continuity reconstruction.After confirming the diagnosis and excluding patients who did not meet the selection criteria, randomization was performed creating two groups by using a computer-generated sequence on EPIDAT ; Universidad CES, Colombia):®® lyophilized live bacteria, marketed by MENDES, S.A, contained 4.5 × 1011 of live bacteria in each preparation:◦Lactobacillus:Four strains of ■®®Lactobacillus acidophilus DSM 24735■®®Lactobacillus plantarum DSM 24730■®®Lactobacillus paracasei DSM 24733■Lactobacillus delbrueckii subsp. bulgaricus DSM 24734®®◦Bifidobacterium:Three strains of ■®®Bifidobacterium breve DSM 24732■®®Bifidobacterium longum DSM 24736■®®Bifidobacterium infantis DSM 24737◦StreptococcusOne strain of ■®®Streptococcus thermophilus DSM 24731Stimulation group (SG): preoperative stimulation with probiotics of the distal limb of the ileostomy loop was performed during the 20 days prior to surgery every second day. During the process and after it, the patient himself registered the appearance of symptoms after each stimulation session: abdominal pain, emission of gas and stool. A sterile Foley catheter No.14 Ch connected to an infusion set was introduced through the defunctioned bowel. This was done to allow slow infusion of a solution of 4.5 mg of probiotics diluted in 250 mL of 0.9% physiological saline for 20–30 min. Each preparation was made under sterile conditions and maintaining the cold chain. VivomixxControl group (CG): exactly the same procedure was carried out, but with the closed infusion set. During the process and after it, the patient himself registered the appearance of symptoms after each stimulation session: abdominal pain, emission of gas and stool.After ten stimulation sessions, 24 h before surgery, a colonoscopy with biopsy was performed on all patients, re-quantifying the index of severity of endoscopic and histological diversion colitis.The reconstruction surgery was carried out by three expert surgeons from the Colorectal Surgery Department. A parastomal incision was made and carried out sharply into the peritoneal cavity. The anastomosis was lateral-lateral, either manual or mechanical, according to the decision of the surgeon. Every surgeon could decide whether to change to a median laparotomy procedure or not. Complications or events happened during surgery were recorded in the surgical procedure protocol. General anesthesia was given to all patients and, after extubation and stabilization in the postoperative recovery room, they went directly to the hospitalization ward.Follow-up during hospitalization was carried out by the team of the Colorectal Surgery department of every center, recording any postoperative complications. Patients were discharged from the hospital after re-establishing intestinal transit, adequate oral tolerance and stool control, recording the length of their hospital stay.Follow-up after hospitalization was carried out by the Colorectal Surgery team in the first, third and sixth postoperative months. These evaluations were performed by the colorectal surgeon who had performed the surgical intervention in each patient. Any symptomatology related to the intervention was recorded, with special monitoring of abdominal pain, number and control of stools, mucous discharge, tenesmus and rectorrhagia. After completing a three-month follow-up, a colonoscopy with biopsies was performed to evaluate the presence and grade of DC.To ensure masking of the patients, all underwent the same diagnostic procedure. During the stimulation sessions, both the solution with probiotics and the infusion set were covered by an opaque protective envelope, which prevented from observing the color and transparency of the fluid, or whether the system was open or closed. The stimulation sessions were performed by a single surgeon, who was also in charge of preparing the dilution.The endoscopist, the pathologist and the surgeon who performed the surgical intervention and the follow-up, as well as the surgeons who participated in the hospitalization process after the surgery, did not know whether the patient had received probiotics or not.The main endpoint was the decrease or disappearance of endoscopic and histological findings in the short-term follow-up, caused by stimulation of the efferent loop with probiotics. The secondary endpoints were the correlation of endoscopic and histological severity with DC symptoms and its decrease or disappearance after stimulation with probiotics and in the short-term follow-up after reconstructive surgery (3 months).p < 0.05 was considered to be significant. Statistical analyses were performed using the statistical program SPSS®® version 24.0 , with the support of calculation tools provided by the software Microsoft Excel and R.A descriptive univariate analysis of sociodemographic and clinical variables was performed. The Kolmogorov-Smirnov test was used to verify the normality of the quantitative variables. To describe the quantitative variables, the mean and standard deviation were used, and the median and interquartile range for those variables that did not follow a normal distribution. For qualitative variables frequencies and percentages were used. Afterwards, to verify the main objectives, a bivariate analysis was performed. A contrast test of proportions based on the Chi-square test was used in order to determine whether stimulation of the efferent loop with probiotics prior to the closure of the protective ileostomy reduced the level of diversion colitis, macroscopic and microscopic findings, as well as its relationship with the appearance of symptoms of diversion colitis. To quantify its level of association, Cramer’s Phi and V coefficients were calculated. In order to correlate quantitative variables, the Spearman’s rank correlation coefficient was used. A The project was performed according to the guidelines of the Declaration of Helsinki, with the authorization of the Ethics Coordinating Committee for Biomedical Research of Andalusia, Spain, registered with the project number 2017/331191354. Written informed consent was requested to participate in the study, giving details of both the study objectives and the methodology to be followed. The data was kept anonymous, maintaining the confidentiality and anonymity of the participants.n = 35) and control (n = 38). 69 patients completed the study, 1 of them from SG and 3 from CG abandoning the study due to anastomotic leak.Between January 2017 and December 2018, 83 disease free patients with protective ileostomy after colorectal carcinoma resection were reviewed and included in the surgical waiting list for intestinal transit reconstruction. 78 of them met the endoscopic and histological criteria for diversion colitis diagnosis and 73 patients were finally randomized into two groups, intervention  and SG (n = 34). Differences were found in the post-stimulation phase where friability of the colonic mucosa was seen in 100% of patients in CG compared to 58.8% in SG (n = 20), where this symptom disappeared in 41.2% of patients (n = 14) with p < 0.001 and a Phi and V Cramer coefficient of 0.948. Friability of the colonic mucosa had already disappeared in both groups after reconstructive surgery in the short-term follow-up.The effects of probiotic stimulation are shown in n = 12) and 58.8% in SG (n = 20). These lesions were observed in colonoscopy after stimulation with probiotics in 34.4% of patients in CG, unlike SG, in which it disappears with p < 0.001 and a Phi and V Cramer coefficient of 0.693. The ulcers disappeared in both groups after reconstructive surgery in the short-term follow-up.The presence of ulcers in the colonic mucosa was found in 34.3% of patients in CG (n = 7) and 23.5% in SG (n = 8). After stimulation with probiotics polyps were still present in 20% of CG whether they reduced to 8.8% of SG (n = 3) with p < 0.001 and a Phi and V coefficient of Cramer 0.781. The inflammatory polyps disappeared in both groups after reconstructive surgery in the short-term follow-up.Inflammatory polyps were present in 20% of patients in CG (n = 35) and SG (n = 34). The distribution of CG according to endoscopic severity was 5 mild (14.3%), 20 moderate (57.1%) and 10 severe (28.6%); contrasting with SG, 9 mild (36.5%), 18 moderate (52.9%), and 7 severe (20.6%). Mucosal edema was maintained in colonoscopy after stimulation with probiotics in 100% of CG with the same distribution of severity, compared to SG, 22 mild (64.7%) and no edema in 12 patients (35.3%), with a p < 0.001 and a Phi and V Cramer coefficient of 0.670. The edema had disappeared in 85.7% in CG (n = 30) and 91.2% in SG (n = 31). In the short-term follow-up, after reconstructive surgery, we observed mild edema in 14.3% in CG (n = 5) and 8.8% SG (n = 3), with a p = 0.479.Mucosal edema was present in 100% in both CG (n = 35) and SG (n = 34). The distribution of CG according to endoscopic severity was 3 mild (8.6%), 22 moderate (62.9%) and 10 severe (28.6%); in contrast to SG, 11 mild (32.3%), 16 moderate (47.1%), and 7 severe (20.6%). Mucosal erythema was maintained in colonoscopy after stimulation with probiotics in 100% of CG with the same distribution of severity, compared to SG, 15 patients (44.1%) and no erythema in 19 patients (55.9%), with a p < 0.001 and a Phi and V Cramer coefficient of 0.976. In the short-term follow-up, after reconstructive surgery, we observed erythema had disappeared in both groups.Mucosal erythema was present in 100% of both, CG (n = 21) and 64.7% SG (n = 22). The distribution of CG according to endoscopic severity was 15 mild (42.9%) and 6 moderate (17.1%), compared to SG, 19 mild (55.9%) and 3 moderate (8.8%). Bowel stenosis was maintained in colonoscopy after stimulation with probiotics in 60% in CG with the same distribution of severity, compared to SG, 5 patients (14.7%) and no stenosis in 29 patients (85.3%), with a p < 0.001 and a Phi and V Cramer coefficient of 0.842. In the short-term follow-up, after reconstructive surgery, we observed stenosis had disappeared in 97.1% in CG (n = 34) and in 100% in SG (n = 34), with a p = 0.321.Bowel stenosis was present in 60% in CG (n = 25) and 88.2% in SG (n = 30) and was maintained after stimulation with probiotics in 71.4% in CG compared to 23.5% in SG (n = 8), being absent in 76.5% in SG (n = 26), with a p < 0.001 and Phi and V Cramer coefficient of 0.683. In the short-term follow-up lymphoid follicular hyperplasia had already disappeared after reconstructive surgery in both groups. Eosinophils were present in 85.7% in CG (n = 30) and 76.5% in SG (n = 26) and it was maintained after stimulation with probiotics in 85.7% in CG compared to 20.6% in SG (n = 7), being absent in 79.4% in SG (n = 27), with a p < 0.001 and Phi and V Cramer coefficient of 0.518. In the short-term follow-up eosinophils were only present in 2.9% after reconstructive surgery in both groups, with a p = 0.182. Crypt abscesses were present in 20% in CG (n = 7) and 20.6% in SG patients (n = 7) and it was maintained after stimulation with probiotics in 20% in CG, less when compared to SG in which were absent in 100% of patients (n = 34), with a p < 0.001 and Phi and V Cramer coefficient of 0.666. In the short-term follow-up crypt abscesses had already disappeared after reconstructive surgery in both groups. Lymphocytic infiltration of the lamina propria was present in 94.3% of patients in CG (n = 33) and 91.2% in SG (n = 31). The distribution of CG according to endoscopic severity was 17 mild (48.6%), 14 moderate (40%) and 2 severe (5.7%) while in SG it was 11 mild (32.4%) and 20 moderate (58.8%). Lymphocytic infiltration of the lamina propria was maintained in 94.3% in CG with the same distribution after stimulation with probiotics, compared to SG with 18 mild (52.9%) and absence in 16 patients (47.1%), with a p < 0.001 and Phi and V coefficient of Cramer 0.692. In the short-term follow-up lymphocytic infiltration of the lamina propria had disappeared in 85.7% in CG (n = 30) and 100% in SG (n = 34) after reconstructive surgery, persisting in a mild form in 14.3% in CG (n = 5), with a p = 0.004 and Phi and V Cramer coefficient of 0.442. Plasma cell infiltration was present in 94.3% in CG (n = 33) and 76.5% in SG (n = 26). The distribution of CG according to endoscopic severity was 14 mild (40%) and 19 moderate (54.3%). However, it was observed in SG 11 mild (32.4%) and 15 moderate (44.1%). Plasma cell infiltration was maintained with the same distribution after stimulation with probiotics in 94.3% in CG compared to SG with 9 mild (26.5%) being absent in 25 in SG (73.5%), with a p < 0.001 and Phi and V Cramer coefficient 0.771. In the short-term follow-up plasma cell infiltration had disappeared in 94.3% in CG (n = 33) and 97.1% in SG (n = 33) after reconstructive surgery, persisting mild infiltration by lymphocytes in 5.7% in CG (n = 2) and 2.9% in SG (n = 1), with a p = 0.190. Destructuring of the crypt architecture was present in 100% in CG (n = 35) and 91.2% in SG (n = 31). The distribution of CG according to endoscopic severity was 8 mild (22.9%), 19 moderate (54.3%) and 8 severe (22.9%), however in SG 4 mild (11.8%), 20 moderate (58.8%) and 7 severe (20.6%) was observed. Destructuring of the crypt architecture was maintained, after stimulation with probiotics, in 100% in CG with the same distribution, compared to SG with 23 mild (67.6%), 2 moderate (5.9%) and absence in 9 patients (26.5%), with a p < 0.001 and Phi and V Cramer coefficient of 0.911. In the short-term follow-up destructuring of the crypt architecture had disappeared in 85.7% in CG (n = 30) and 100% in SG (n = 34), persisting mild alteration of the architecture in 14.3% in CG (n = 5) after reconstructive surgery, with a p = 0.002 and Phi and V Cramer coefficient of 0.471.The effects of probiotic stimulation were depicted in p = 0.911), with 9 patients with severe diversion colitis in both groups (26.5% SG vs 25.7% CG), 23 patients with moderate diversion colitis in both groups (67.6% SG vs 65.7% CG) and 2 patients with mild diversion colitis in SG (5.9%) versus 3 patients in CG (8.6%). The associated symptoms were abdominal pain, mucous discharge, urgency, and rectal bleeding (n = 15) and 51.4% in CG (n = 18). Mucous discharge was present in 61.7% of patients in SG (n = 21) and 40% in CG (n = 14). Tenesmus appeared in 14.7% in SG (n = 5) and 5.7% in CG (n = 2). Rectorrhagia was observed in 5.9% in SG (n = 2) and 11.4% in CG (n = 4).We found a homogeneous distribution in the diversion colitis degree in pre-stimulation phase between SG and CG (bleeding . Abdominn = 0), 3 patients with moderate diversion colitis (8.8% CG), 19 patients with mild diversion colitis (55.9%) and 12 patients with normal endoscopic and histological findings (35.3%), achieving a p < 0.001 and a Phi and V Cramer coefficient of 0.834. After stimulation and reconstructive surgery, DC symptoms were present in 100% in CG (n = 35) compared to 14.7%in SG (n = 5) with a p < 0.001 and Phi and V coefficient of Cramer 0.789. The associated symptoms in CG were diarrhea in 85.7% (n = 30), abdominal pain in 57.1% (n = 20), urgency in 34.3% (n = 12) and rectal bleeding in 5.7% (n = 2). The associated symptoms in SG were abdominal pain in 11.7% (n = 4) and tenesmus in 5.9% (n = 2). In the post-stimulation phase, CG maintains its distribution with 9 severe DC (25.7%), 23 moderate DC (65.7% CG) and 3 mild DC (8.6%); on the other hand, SG shows no patients with severe DC (n = 0), 3 patients with moderate DC (8.8% CG), 19 patients with mild DC (55.9%) and 12 patients with normal endoscopic findings (35.3%), achieving a p < 0.001 and Phi and V Cramer coefficient of 0.883.In the post-stimulation phase, CG maintains its distribution with 9 patients with severe diversion colitis (25.7%), 23 patients with moderate diversion colitis (65.7% CG) and 3 patients with mild diversion colitis (8.6%); on the other hand, SG shows no patients with severe diversion colitis (n = 10) compared to 71.4% who were asymptomatic (n = 25). SG showed 100% asymptomatic patients after surgery, with p < 0.001 and a Phi and V Cramer coefficient of 0.406. The persistent symptoms in CG were diarrhea 28.6% (n = 10), abdominal pain 22.8% (n = 8) and tenesmus 5.7% (n = 2).Finally, during the short-term follow-up after reconstructive surgery, symptoms were present in CG with 28.6% (In our study, macroscopic and microscopic alterations associated with DC dysbiosis were observed in both CG and SG without observing a statistically significant relationship between severity, symptoms, or time since the creation of the stoma, findings similar to those published in previous studies ,26,27,28Most of the clinical research on DC was carried out during the 90’s and early 2000’s with the aim of identifying the molecular mechanisms that triggered this disease, its endoscopic and histological characteristics, and its relationship with the microbiota alteration ,30,31,32Based on studies such as the one published by Morgan et al. in 2020 , which dThe results of this study, at the macroscopic level, demonstrated a significant decrease in all endoscopic findings in SG compared to CG, with a strong correlation between stimulation of the efferent loop with probiotics and a decrease in macroscopic findings on colitis. It was worth highlighting a notable decrease in the severity of the edema and mucous erythema, turning from severe or moderate to mild or simply disappearing, a fact that we relate to the anti-inflammatory effect of probiotics, and a complete disappearance of the ulcers in the SG after the stimulation phase, also with an intense correlation, as we can see in Morphological studies about colonic biopsies in patients with ileostomy have shown chronic inflammation in more than 50% of the samples, with an increase in lymphoid tissue in 100% of the cases ,40. The The observations presented here demonstrate that the decrease in endoscopic and histological findings associated with the decrease in inflammation means that stimulation of the efferent loop of the ileostomy with probiotics can be an alternative treatment in patients with symptomatic DC who are not candidates for reconstructive surgery as a treatment to resolve the colonic inflammation. Finally, the stimulation of the efferent loop with probiotics can be an alternative treatment to resolve the inflammation in patients whose surgical option is not feasible or available.There are few studies on endoscopic and histopathological DC after reconstructive surgery, with limited information on follow-up. A Korean study published by Son et al.  found anTherefore, we can conclude that stimulation of the efferent loop with probiotics seems to have a reducing effect on the endoscopic and histopathological alterations in DC and consequently, this procedure can be an alternative treatment for patients where surgical option is not feasible or available. Nevertheless, we will need more multicenter studies based on macroscopic and microscopic changes after stimulation prior to closure ileostomy to support these conclusions.


Maternal anemia is a common problem in developing countries like Nepal accounting for around 30-50% of women becoming anemic during pregnancy. The present study aims to find out the prevalence of maternal anemia in a tertiary care hospital in Western Nepal.A descriptive cross-sectional study was carried out at Devdaha Medical College, Bhaluhi, Rupandehi, Nepal from October 2018 to May 2019 after taking ethical approval from the institutional review committee with the approval number: 012/2018. Three eighty three samples were taken and convenient sampling was done to reach the sample size. Data were collected from the study population after taking consent and entered in a predesigned proforma. It was then entered in an SPSS; point estimate at 95% CI was calculated along with frequency and proportion for binary data.During the study period, out of 383 mothers, 230 (60.2%) mothers were anemic at 95% CI (10.6-10.8%); of which 172 (74.8%) were moderately anemic while 58 (25.2%) were mild anemic. The mean maternal Haemoglobin was 9.5±1.76SD. The mean maternal age was 24.24±3.26 SD; mean gestational age at the time of delivery was 36.08±1.77 SD.The prevalence of maternal anemia in this study is found to be higher than the national data which implies that maternal anemia is still a public health issue which needs to be addressed in spite of safe motherhood program launched by the government of Nepal. This gestational outcome is considered as a major public health concern; it is more prevalent in countries with low financial resources.The objective of the study was to find the prevalence of maternal anemia in a tertiary care hospital in Western Nepal.This hospital-based descriptive cross-sectional study was conducted from October 2018 to May 2019 at Devdaha Medical College, Bhaluhi, Rupandehi, Nepal after taking ethical approval from the institutional review committee (IRC) of the college. The present study included 383 pregnant mothers>18 years of age with ANC visits done at Devdaha Medical College with a singleton pregnancy using consecutive sampling method. Those pregnant women with multiple pregnancies, history of preterm delivery and with any obstetrical complications or medical illness except anemia were excluded from the study. We took a written consent from the mother to participate in the study for the mothers. A detailed history was taken from the mother during the presentation for delivery and the data of the mothers was entered in the predesigned proforma. The blood of the mothers were collected from the antecubital vein and stored in the EDTA containing vial and then analysed using the automated hematologic analyzer.Maternal anemia was defined as Hb<11 g/L. All the information including gestational age at the time of delivery, mode of delivery, clinical signs and symptoms, indication for admission in NICU, maternal risk factors, were recorded in the predesigned proforma. The perinatal outcome was defined as the maternal and fetal consequences caused by maternal habits and pregnancy complications during labor and one hour after delivery. The maternal consequences included preterm delivery, prolonged labor and maternal mortality whereas fetal consequences included small for gestational age, low Apgar score, intrauterine growth retardation, and intrauterine death. The fetal outcomes were small for gestational age, congenital anomalies, low birth weight, stillbirth, respiratory distress syndrome, preterm babies, intrauterine growth retardation, low Apgar score less than 5 at 1 min and birth asphyxia.82 ×pq/d2Sample size = Z2    = 3.84 × 0.48×0.48/ (0.05)    = 383Z =1.96 at 95% CI.6p= prevalence of maternal anemia, 48%q= 1-pe= margin of error, 5%Convenient sampling was done and the sample size was calculated using the formula,The total sample size calculated was 383.The mothers were followed until discharge or death. In case of death, the cause of mortality was recorded. Data were checked for any errors or inconsistencies, then entered in a Statistical Package for Social Sciences (SPSS), point estimate at 95% CI was calculated along with frequency and proportion for binary data.The prevalence of maternal anemia was found out to be 60.2% at 95% CI (10.6-10.8%) in our study. During the study period, 383 mothers and their newborn babies were evaluated. Out of them, 230 (60.2%) mothers were anemic; of which 172 (74.8%) were moderately anemic while 58 (25.2%) were mild anemic. No one was found to be severely anemic. The mean maternal Haemoglobin was 9.5±1.76 SD. There were 366 (95.5%) live-born, stillbirth 03 (0.8%) and IUFD 14 (3.7%) babies. The mean maternal age was 24.24±3.26 SD, ; mean gestational age at the time of delivery was 36.08±1.77 SD. The mean birth weight of the baby was 2.35±0.374kg. Male: female ratio was 1.4:1.Perinatal mortality in our study was 44.3 per thousand population. In mothers with anemia, low birth weight was seen in 161 (42.0%) at 95% CI (2.312.38) cases and most of the mothers were from rural area 261 (68.1%). The demographic characteristics of our study population are depicted .Among anemic mothers, anemia was found prevalent at 37 weeks of gestation following second most at 35 and 36 weeks respectively .One hundred and sixty one (42%) mothers with maternal anemia delivered low birth weight babies .Perinatal outcome of babies born to anemic mothers showed live born in 224 (97.4%), low birth weight in 161 (42%), Preterm in 130 (56.5%), IUGR in 55 (23.9%), NICU admission in 39 (17%), anemia in baby in 14 (6.1%), IUFD in 10 (4.3%) and stillbirth in 2 (0.9%) .12 NDHS data set 2016 showed a prevalence rate of 40%.13 Our study revealed 74.8% of mothers were moderately anemic while 58 (25.2%) were mildly anemic. This indicates that the nutritional significance of nutrition is subordinate and awareness is made to the rectification of anemia in the pre-pregnancy period.During the study period, 383 mothers along with their newborns were included, of which 230 (60.2%) proportions of mothers were anemic. The prevalence of maternal anemia was found out to be 60.2% at 95% CI (10.6-10.8%) in our study. This is similar to a study reported from India 9 (60.38%) and 10 (62.3%) while it is in contrast to some studies done in other parts of Nepal which showed a low prevalence rate ranging from 42 to 48%.14 which showed the mean maternal haemoglobin concentration to be 11.14 ± 1.39 gm/dL.Our study showed mean maternal haemoglobin to be 9.5±1.76 gm/dL which is near to comparable from a study done in Nepal15 Mean gestational age at delivery was 36.08±1.77 which is similar to a study done in England16 and in Nepal.17Mean maternal age in our study was a 24.24±3.26 year which is similar to a study done by Timilsina et al.18This study showed that the maximum number of mothers 261 (68.1%) were from the rural area. The percentage of low birth weight babies were more in mothers from a rural area 24.6% as compared to urban areas 13.5%. This was similar to a study done by Yadav et al where 84% mothers residing in rural areas of terrain region of Nepal had a proportion of LBW in rural 21.71% and urban 20.83% areas.19 and 9.8% in a study done in Nepal.18 Another study showed the prevalence rate of 23.6%.20 In the present study out of the total low birth weight babies, 56.2% were males and 43.8% were female which is similar to a study done by Ahmed et al20 while it is in contrast to a study done by Hussain et al in Pakistan which showed the incidence of male 45.2% and female 55%.21Our study showed the mean birth weight to be 2.35±0.37 kg. Low Birth Weight was seen in 161 (42.0%) cases of anemic mothers which is very high and is in contrary to a study done by Acharya et al which showed to be only 19.4%22 Perinatal mortality in our study was 44.3 per thousand population which is similar to a study done 42%.23Our study showed mothers having preterm delivery were 23.4% and the proportion of low birth weight was high. A study from Karnataka showed the preterm birth was 38%.The high prevalence rate of maternal anemia in this study implies that maternal anemia is still a public health issue which needs to be addressed in spite of the safe motherhood program launched by the government of Nepal. Low maternal haemoglobin levels are associated with increased risk of stillbirth and IUD, and LBW babies. The prevalence of low birth weight was found to be significantly high among institutional deliveries of this region of the country.None.


The present study aims to determine the structure of morbidity in workers contacting industrial aerosols, assess the timeliness of diagnosing dust-induced lung disease in major industrial centers, and optimize diagnostics for early detection of occupational lung diseases in workers exposed to industrial dust hazards.The study on the structure and incidence of occupational lung diseases was carried out in 2016–2020 based on the Moscow Centre for Occupational Pathology data. For a more in-depth clinical examination, 114 patients who were first admitted to the Occupational Pathology Centre with diagnosed pneumoconiosis (PC), chronic dust-induced bronchitis (CDB), and chronic obstructive pulmonary disease (COPD) were selected. All patients were subjected to a complex clinical-functional, spirographic, echocardiographic, fibroscopic, radiological, and CT lung examination, with subsequent analysis of the results obtained. The pathology caused by exposure to industrial aerosols within the studied period was first diagnosed in 344 workers. Most patients (64%) with newly detected pathologies were 50–59 years of age, with work experience in adverse conditions of 21–25 years (41%).The spirographic study of respiratory function revealed decreased forced vital capacity (FVC) indices in CDB and COPD patients. Changes in expiratory flow rates suggest occupational bronchitis at an earlier stage, whereas no apparent results were noted for the PC diagnosis. The results of fibroscopic examination in PC patients revealed atrophic processes of the bronchial mucosa in 46 (88.5%) of them, and 6 (11.5%) patients had a subtropic process. The results of echocardiographic examination allowed diagnosing pulmonary heart disease in 83 patients (72.8%). Of them, 42 (80.8%) were revealed in the group of patients with PC, 18 (50.0%) in the COB group, and 14 (53.8%) in the COPD group.Computed tomography (CT) detected pathological changes in 52 patients, while the X-ray examination in six people showed no evidence of lung destruction. CT scan also showed that the number of patients with fibrotic PC (including silicosis) in the study groups increased. Timely clinical and functional examination  of patients allows detecting PC (including silicosis), CDB, and COPD at an early stage of disease progression. Lung diseases related to environmental problems are becoming more relevant and socially important . Long-teAccording to medical statistics in Aktobe region up to 25% of applications for medical care are related to respiratory diseases. As of 2020 in the region and Aktobe city there are higher rates of bronchitis morbidity per 100 thousand people than in the Republic of Kazakhstan as a whole both among adults and adolescents. Thus, in Aktobe region there were 389 cases of bronchitis per 100 thousand adults and 587 cases among adolescents, this figure for the Republic of Kazakhstan as a whole is 272 and 408 cases respectively .Adverse production factors frequently aggravate exposure to industrial dust. They include microclimate, heavy physical labor, unfavorable environment , age, upper respiratory tract infections, genetic predisposition, and smoking, which intensifies the effect of industrial aerosols .At the same time, within the overall polyclinic network, diagnosis of occupational diseases due to exposure to industrial aerosols remains quite rare. Most occupational pathologies are detected only when workers seek medical care . Such a The present study aimed to determine the structure of morbidity in workers contacting industrial aerosols and assess the timeliness of diagnosis of dust-induced diseases in a large industrial center. Besides, consideration was given to optimizing diagnostics for early detection of occupational lung diseases in workers exposed to dust hazards.The study on the structure and frequency of occupational lung diseases was conducted based on the Moscow City Center and Aktobe City Center for Occupational Pathology materials in 2016–2020. The dynamics of early-detected (‘primary’) occupational lung diseases following exposure to industrial aerosols during the specified period were evaluated.The diagnosis of PC, moderate COB (dust-induced and toxic dust-induced) in remission, II-degree COBP without exacerbation;No concurrent conditions ; andConsent to be included in the study.Clinical examination enrolled 114 patients admitted to the Centre for Occupational Pathology for the first time and matched the following selection criteria:Smoking;Stages II and III hypertension;Coronary heart disease;Circulatory insufficiency of IV functional class (FC);Comorbid conditions; andUse of angiotensin-converting enzyme (ACE) inhibitors and ß-Adreno-blockers.The exclusion criteria were:The average age of the examined patients was 56.4 ± 7.32 years. The average time spent working under adverse conditions was 21.5 6.87 years. The majority of the patients studied were aged 50–59 years, i.e., the most skilled workers of pre-retirement age, with more than 20 years of working experience in contact with industrial aerosols.All patients examined were allocated to three nosological groups. The first group enrolled 52 patients diagnosed with PC and silicosis. The second group comprised 36 patients diagnosed with dust-induced and toxic dust-induced bronchitis. Finally, the third group included 26 COPD patients.The nosological features of patients by sex, age, and work experience in hazardous working conditions are presented in Table Typical symptoms of the above pathologies, such as dyspnea at rest and after exercises, cough, chest pain, and increased fatigue, were investigated to evaluate the patients’ clinical status.All patients underwent complex clinical and functional examination, bronchoscopy, radiology, and a pulmonary tomography examination. Pulmonary ventilation function was assessed by computer spirography on the Custo Vit device (Germany). Prior to the examination, all active-acting medications on the smooth muscle tone of the bronchi were canceled. A bronchodilatation test with fenoterol hydrobromide was used to assess the reversibility of bronchial obstruction. The study was carried out in the morning, on an empty stomach, and in conditions of relative rest (sitting) using nasal clips to exclude the effect of circadian rhythm on the result.An echocardiographic study was performed on the Hewlett Pascard Sapos-1000 (Japan) device by standard technique: M-mode and two-dimensional mode from the left parasternal position near the tips of the mitral valve leaflets.The fibrobronchoscopic examination was carried out with the FV-ZS Olumpus (Japan) bronchoscope under local anesthesia (1% lidocaine solution). Afterward, the state of the bronchial tree and trachea was visually assessed.Chest radiography was performed according to the standard procedure. The Valsalva test modified by Kuznetsov was applied to distinguish vascular and fibrous changes of the lungs if required. The severity of the coniotic process was estimated based on the nature of the pathological changes detected, their shape, size, profusion and prevalence in the lung fields. Small changes were distinguished as nodular shadows , linear thrusts , and large changes “A”, “B”, “C”; fibrous changes in pleura and lung roots, diffuse changes as pleural overlay (thickening) and local changes were marked as “a”, “b”, “c” plaques.Completeness of coverage of the studied object;Correct positioning of the patient during imaging;The clarity of the radiograph;The contrast of the radiograph; andThe stiffness of the radiograph.The quality of the chest radiographs obtained was evaluated using the following criteria:CT scans of the thoracic organs were performed using a 32 slice Toshiba Aquilion Multi 32 slice (Japan) CT system. Patterns, i.e., pathology features, were used to evaluate CT scans. Thus, the nodular pattern implies small nodules with a diameter ranging from 1 to 10 mm. Linear pattern includes thin irregular lines, thin linear densities, and reticulated linear densities. Data on the prevalence of pathological processes allowed distinguishing between thickening of the axial interstitium, interfollicular and intradollicular septa, the sign of “honeycombs” , subpleural lines, and centrilobular star points.2 criterion. For two-dimensional contingency tables, statistical significance was assessed using Fisher’s exact test. Descriptive statistics used in this paper are arithmetic mean (M) and standard deviation (s)—M ± s. The critical value of the significance level (p) was taken to be 0.05.Statistical analysis of the study results was performed with the specialized software SPSS 21. Prior to research, the law of quantitative indices distribution was investigated using Kolmogorov–Smirnov and Shapiro–Wilk criteria. Thus, the distribution of the studied indices was close to the normal values, with no significant outliers, asymmetry, and kurtosis indices. Comparisons of independent groups with various forms of lung pathology were made using a univariate analysis of variance (ANOVA); comparisons of individual groups with each other were made using the Dunn criterion. For multiple comparisons, the Bonferroni type adjustment was used. The contingency tables were analyzed with the calculation of χAccording to the Moscow City Center and Aktobe City Center for Occupational Pathology data for 2016–2020, diseases caused by exposure to industrial aerosols were first identified in 344 workers. Thus, COB was detected in 202 (58.7%) patients, PC (quartzose dust-induced > 10%) in 59 (17.2%), silicosis (quartzose dust-induced < 10%) in 27 (7.8%), silicotuberculosis in 3 (0.9%), and COPD in 53 (15.4%) patients  with newly detected conditions ranged from 50 to 59 years of age. Patients in the 60–69 age group accounted for 16%, the 40–49 age group for 12%, the under-40 age group for 5%, and the 70+ age group for 3% , accounting for 43%. Miners comprised 17%, cement production workers—16%, electric and gas welders—14%, other occupations occupied 10% ; harsh breathing was observed in 63.2% of patients . Dry rales during forced exhalation were noted in 66.7% of patients .Symptoms of rhinopharyngolaryngitis were noted in 23.5% of patients with PC (20.8%). There are also upper respiratory tract symptoms in 61.1% of dust-induced COB patients and 26.9% of COPD patients.Thus, in all three groups of dust-induced diseases, the most frequent signs were increased fatigue, shortness of breath on exertion, harsh breathing, and dry rales. According to patients’ complaints, anamnesis, and physical examination, the characteristics of PC, COB, and COPD clinics are similar.Further clinical examination involved 114 patients with a primary diagnosis of the occupational respiratory disease, who met the selection criteria. Depending on the diagnosis, these patients were divided into three groups: patients diagnosed with PC (group 1), patients diagnosed with COB (group 2), and patients diagnosed with COPD (group 3).Spirography results in the group of patients with PC detected reduced FVC of lungs at the level of 87.4 ± 7.6% when assessing external respiratory function. Decreased FVC up to 77.5 ± 8.3% was noted in patients with COB. FVC in patients with bronchitis was lower than in those diagnosed with PC (p < 0.05). In patients with occupational COPD, there was a significant decrease of FVC index to 62.8 ± 6.4% .In patients with PC, the forced expiratory volume in the first second (FEV1) comprised 86.7 ± 8.8%, and the FEV1/FVC ratio, also called the Tiffeneau-Pinelli index, was 94.7 ± 9.6%, indicating restrictive changes. A downward trend was observed in FEV1 values in patients with COB . A more significant decrease in FEV1 was found in COPD patients, amounting to 61.3 ± 6.1% (p < 0.05). FEV1/FVC was 82.6 ± 8.2% (p < 0.05) in COB patients and 58.3 ± 10.6% (p < 0.05) in COPD patients.In the group of patients with PC, the maximum volume rate at the level of 25% of forced vital capacity of lungs (MEF25%) was 78.4 ± 7,1%. Significant decrease of MEF25% was noted in COB with 62.7 ± 7.7% (p < 0.05) and COPD patients with 51.4% ± 8.3% (p < 0.05). Peak expiratory flow rate (PEFR) in patients with PC was registered at 73.8% ± 9.4%. For patients with COB and COPD, this value was 66.3 ± 6.8% (p < 0.05) and 48.4 ± 7.3% (p < 0.05), respectively  in 5 patients (9.6%), I-degree respiratory failure (RF I) was revealed in 31 patients (59.6%), and II-degree respiratory failure (RF II) was recorded in 16 patients (30.8%). In 36 COB patients, RF 0 was registered in 8 persons (22.2%), RF I in 23 (63.9%), and RF II in 5 (13.9%). In 26 COPD patients, RF 0 was observed in 3 patients (11.5%), RF I in 15 (57.7%), and RF II in 8 (30.8%) . Of them, 42 (80.8%) were from PC group, 18 (50.0%) represented COB patients, and 14 (53.8%) had COPD. At the same time, decompensated pulmonary heart disease (with different decompensation degrees) was observed in 53.6% across all groups  was revealed in 13 patients (31.0%), II FC in 24 57.1%) patients, and III FC in 5 patients (11.9%). In 18 patients with pulmonary heart disease in the group of COB patients, circulatory insufficiency I FC was revealed in 3 patients (16.7%), II FC in 11 patients (61.1%), III FC in 4 patients (22.2%). Among 14 COPD patients with this pathology, the findings were as follows: circulatory insufficiency I FC was observed in 3 persons (21.4%), II FC in 8 persons (57.2%), and III FC in 3 persons (21.4%) , COPD (p < 0.01), PC (p < 0.01), which suggests right ventricular hypertrophy in response to increased stress. Authentic increase of the diastolic size of the right ventricle (p < 0.01), a decrease of left ventricular stroke volume (p < 0.05), a decrease of respiratory minute volume (p < 0.05), a decrease of ejection fraction (p < 0.01), shortening fraction (p < 0.05) were observed in all groups. Furthermore, a significant increase of systolic pressure in the pulmonary artery was detected (p < 0.001). The resulting data indicate hypokinetic type formation of central hemodynamics.Fibroscopic examination of patients with pneumoconiosis showed atrophic processes of the bronchial mucosa in 46 (88.5%), and 6 (11.5%) patients had subatrophic processes. Among patients with COB, mucous membrane atrophy was revealed in 22 (61.1%) patients, subatrophic process in 11 (30.6%), and catarrhal symptoms were observed in 8.3% of cases (3 patients). Atrophy of pulmonary mucosa was stated in 8 COPD patients (30.8%), subatrophic changes of bronchial mucosa were observed in 15 patients (57.7%), and catarrhal changes in 11.5% cases (3 patients).In the group of patients with PC, interstitial changes in the form of linear bands up to 1.5 mm in diameter (gradation “s”) were detected in 30 patients (57.7%). Among them, 2 s-grade was recorded in 22 patients (42.3%), and 1 s-grade in 8 patients (15.4%). Interstitial changes in the form of bands with a diameter ranging from 1.5 to 3.0 mm (gradation “t”) were revealed in 12 patients (23.1%). Of them, 10 patients (19.2%) had 2t-grade and 2 patients (3.8%) had 1t-grade. Nodular changes of 1r-grade were found in 3 patients (5.8%), and nodules with diameters between 1.5 and 3.0 mm of q-grade were revealed in 2 patients. Also, there were two patients with 3q and 2q grade profusion. Radiography revealed no changes in 5 patients (9.6%).According to CN scans, interstitial changes in the form of linear bands up to 1.5 mm in diameter (gradation “s”) were found in 22 patients (42.3%) with PC. Of them, 2 s-grade was recorded in 17 patients, and 1 s-grade in 5 patients. Interstitial changes in the form of bands with a diameter ranging from 1.5 to 3.0 mm (gradation “t”) were detected in 19 patients (36.5%). Among them, in 2t was stated in 16, and 3t—in 3. Two patients (3.8%) demonstrated changes looking as bands more than 3.0 mm in diameter and grading 3u. Nodules up to 1.5 mm in diameter were found in 4 patients (7.7%) with 1p-grade. Nodular shadows ranging between 1.5 and 3.0 mm in diameter (gradation “q”) were detected in 5 patients (9.6%), with density classified as 1q (3 patients) and 2q (2 patients). Shadows in the form of nodules greater than 3.0 mm in diameter were detected in 2 patients, one each of 2r and 3r grades.CT method allowed detecting pathological changes in all 52 patients, while X-ray examination in six people showed no signs of lung lesions. CT scanning showed that the number of patients with nodular PC forms (including silicosis) in the studied groups was also increased.The analysis of X-ray and CT scan data of COB patients showed an insignificant intensification of bronchial vascular pattern that in 92% of patients (according to X-ray data). No pathology was observed in 8% revealed. The diagnosis in this group of patients was made based on the complaints, medical history, physical examination findings, changes in external respiration function indices, fibrobronchoscopy data, sanitary and hygienic features. According to CT findings, bronchial vascular pattern enhancement was detected in all patients. Furthermore, in 19.4% of cases (7 examined patients), its deformity was detected in addition to enhancement.In the group of patients with established COPD diagnosis, an increased bronchial vascular pattern was noted in 63.7% of cases. At CT investigation, all patients were found to have increased bronchial vascular patterns, with no deformity detected in 5 of them (19.2%).According to the results of the radiological examination, only 8 cases (15.4%) showed the signs of pulmonary emphysema in the form of widened intercostal spaces, diffuse increase in transparency, or local areas of lung tissue transparency in the group of patients with the diagnosis of PC. The CT diagnostics revealed the signs of emphysema in 38 patients (73.1%). When evaluating CT data of the lungs, small paraseptal air cavities in the apices were revealed in 17 patients, small paraseptal and centrilobular air cavities in 18 patients, multiple small paraseptal air cavities in mediabasal parts of the lungs in 3 patients.No emphysema was detected in the group of patients with COB during radiological examination. According to CT scans, emphysema was detected in 17 COB patients (47.2%). Of them, small paraseptal and centrilobular air cavities were observed in 14 patients, multiple small paraseptal air cavities in 2, and panlobular areas of decreased lung tissue pneumotization was observed in one patient had.According to radiological examination, there were no signs of emphysema in the group of patients diagnosed with COPD. They were detected only during lung CT investigation in 10 patients (38.5%) and appeared as small (6 patients) and multiple (4 patients) paraseptal air cavities in the lung apices.X-ray examination revealed no pathological changes of the pleura in any of the PC patients examined. According to CT scans, pleural thickenings were observed in 28 patients (53.8%). Pleural thickenings up to 5 mm wide (gradation “a”) were registered in 18 patients (45.8%), and pleural thickenings with width from 5 to 10 mm (gradation “b”) in 11 patients.The problem of optimizing diagnostics of early manifestations of occupational dust-induced lung diseases is caused by the aggravation of initially detected occupational pathology, the predominance of expressed chronic diseases, and the affection of multiple organism’s systems , 11. TheThe study of clinical symptoms in patients with PC and COB showed that their primary complaint was increased fatigue. Patients with COPD were most often bothered by dry coughing. Dyspnea during physical exercising was noted in all three groups. A major symptom was the reduced work capacity complaint, and patients had to be assessed for the degree of disability. There were no patients without typical complaints in all groups examined. That is, at admission to the Center for Occupational Pathology, clinically developed signs of the disease were already evident upon results of radiography, spirometry, and bronchoscopy. It underlines the need to improve examination procedures for a possible earlier diagnosis of disease.The framework of this study provided for a clinical and functional examination of patients with diagnosed PC (including silicosis), COB, and COPD to optimize available diagnostic measures.The spirography study revealed a decrease in FVC indices in COB and COPD patients.The main spirographic indices of the obstructive syndrome are deceleration of forced expiratory volume in one second due to increased airway resistance and decreased forced expiratory volume (FEV1) and the Tiffeneau index , 26. TheThe most sensitive spirographic index indicating the increase of airway resistance is the index of mean forced expiratory flow rate at the level of 25–75% (MEF 25–75%) of FVC . A sharpA relative decrease in MEF25% was observed in the COB group, whereas it was significantly lower than normal in the COPD group. A similar pattern in these groups was observed when recording the peak air volume rate (PEFR) index. No significant dynamics of PEFR were found in patients with PC.Decrease of expiratory rate indices MEF25%, along with FEV1 and PEFR, is an initial sign of bronchial permeability disturbance and can be registered earlier than clinical symptoms develop. It allows stating latent bronchoconstriction in these patients . The stuFibrobronchoscopy is very important in the diagnosis of bronchial disease . The datThe severity of the disease was examined in all patient groups, and complications were determined based on the combination of clinical symptoms and diagnostic studies. Thus, respiratory distress was revealed in 84.6% of all examined patients, and respiratory distress indices corresponded to I degree in 54.6% and II degrees in 30.0% of patients. In all kinds of respiratory distress due to lack of oxygen in the blood and hypoxia, compensating reactions of organs and tissues develop. Long-term chronic respiratory distress leads to the right ventricular heart failure progression due to a lack of oxygen in the heart muscle and constant overload .Following an echocardiological examination, chronic pulmonary heart disease at the decompensation stage was diagnosed in more than half of the patients in each group. The above data indicate that 84.7% of patients with pathological conditions due to exposure to industrial aerosols had complications of the underlying disease in the form of respiratory distress and chronic pulmonary heart disease. The study results confirm that occupational lung disease is more often diagnosed late when the complications result in disability and reduced quality of life .For optimizing early diagnostics of occupational dust-induced diseases of the respiratory tract and lungs, the signs of standard radiological examination and data of lung CT scans were analyzed.Radiography remains the primary method in diagnosing occupational lung disease due to exposure to aerosols, and only CT is recommended in particular cases .The present study has shown that CT scanning of the lungs makes it possible to detect pathological changes in the lungs, which are usually not detectable by X-ray imaging. The CT method should be used more extensively in the study of respiratory dust-induced diseases. Multispiral CT allows complementing the radiological picture. In particular, it specifies the extent of pathological processes, visualizes interstitial changes of lung tissues, detects emphysema, determines pathological thickening of pleura and pathological changes in bronchovascular pattern, as well as detects elements, which cannot be diagnosed by X-ray analysis.The third place in the structure of occupational diseases diagnosed every year in Moscow Center for Occupational Pathology belongs to occupational lung diseases with respiratory distress. A detailed clinical condition was defined when diagnosing lung diseases, including respiratory distress, chronic pulmonary heart disease, and emphysema of the lungs. It attests to the late diagnosis of this group of conditions in the pre-hospital stage. Timely clinical and functional examination  of patients during obligatory occupational examinations will allow diagnosing PC (including silicosis), COB, and COPD at an early stage of disease progression.Multispiral CT of lungs is a highly informative diagnostics method of interstitial diseases of respiratory organs, including PC (2.5 times increased detection of nodular changes in comparison with X-ray method). The CT study of the lungs helps to specify the nature, extent, and profusion of pathological processes in the lung, verify the main diagnosis at the early stages of its progression, and reveal complications of the main diagnosis.


Cervical cancer is the second commonly diagnosed cancer and the second leading cause of cancer death in women in Ethiopia, with rates among the highest worldwide. However, there are limited data on cervical cancer treatment patterns and survival in the country. Herein, we examine treatment patterns and survival of cervical cancer patients treated in Tikur Anbessa Hospital Radiotherapy Center (TAHRC), the only hospital with radiotherapy facility in the country.Women with histologically verified cervical cancer who were seen in 2014  at TAHRC were included. Information about clinical characteristics and treatments were extracted from the patients’ medical record files. The information on vital status was obtained from medical chart and through telephone calls.Among 242 patients included in the study, the median age at diagnosis was 48 years. The median waiting time for radiotherapy was 5.6 months (range 2 to 9 months). Stage migration occurred in 13% of patients while waiting for radiotherapy. Consequently, the proportion of patients with stage III or IV disease increased from 66% at first consultation to 74% at the initiation of radiotherapy. Among 151 patients treated with curative intent, only 34 (22.5%) of the patients received concurrent chemotherapy while the reaming patients received radiotherapy alone. The 5-year overall survival rate was 28.4% (20.5% in the worst-case scenario). As expected, survival was lower in patients with advanced stage at initiation of radiotherapy and in those treated as palliative care.The survival of cervical cancer patients remains low in Ethiopia because of late presentation and delay in receipt of radiotherapy, leading to stage migration in substantial proportion of the cases. Concerted and coordinated multisectoral efforts are needed to promote early presentation of cervical cancer and to shorten the unacceptable, long waiting time for radiotherapy. Cervical cancer is the fourth most common type of cancer among women worldwide , 2. Of tEthiopia with the population of more than 110 million, is among countries with the highest incidence rate of cervical cancer worldwide, with about 6000 new cases diagnosed each year . CervicaThe study was carried out in adult oncology department of Tikur Anbesa Specialized Hospital (TASH) radiotherapy center, under the Addis Ababa University. During the study period in 2014 , there were three clinical oncologists, six residents, one General practitioner, and one palliative care physician serving the center. The center had two cobalt-60 radiotherapy machines. The center had no brachytherapy machine during the study period.Patients with cervical cancer were referred from all over Ethiopia to Tikur Anbessa Hospital Radiotherapy center for radiotherapy. Up on first oncologist consultation and/or radiotherapy planning, tumor stage were classified according to the International Federation of Gynecology and Obstetrics (FIGO) staging system . The staAccording to the treatment protocol of the center, cervical cancer patients FIGO stage IIA and lower were treated surgically with radical hysterectomy and pelvic lymphadenectomy (Wertheim). Patients with FIGO stage IIB and above without surgery or patients who undergone surgery but has positive surgical margins and positive lymph nodes required radiotherapy. Patients with early stage disease but unable to undergo surgery due to other medical conditions also treated with radiotherapy. The radiotherapy planning techniques were two-dimensional (2D-technique). Generally, patients with early stage IIIB and/or stage less than early IIIB with good general condition were treated with curative dose radiotherapy in two phases. However, for patients with FIGO stage above late stage IIIB and/or for patients in emergency state palliative radiotherapy is usually offered. The radiation dose and fractionation depend on the intent of treatment, with curative intent cases treated with conventional RT with radiation dose of 66–72 Gys in two phases while palliative intent cases treated with hypofractionation with varied radiation doses which could be 10 Gys single fraction, 20 Gys in 5 fractions, 30 Gys in 10 fractions based on disease stage and general health status of the patient .Women with histologically verified Cervical cancer  codes C53.0–9) who were treated in 2014 at the Radiotherapy Center at Tikur Anbessa Hospital Addis Ababa, Ethiopia, were included in the study, retrospectively.Information on demographic and tumor characteristics, treatments, and response to treatment at 1 year was extracted from the patients’ medical record files. The date of diagnosis was assigned as the date of referral with the suspicion of cervical cancer or the date of biopsy confirmation, whichever is first. Information on vital status was obtained from medical records or the patients or –in case of death- from the relatives through telephone calls. If patients or relatives were not reached by telephone, the last date of personal contact in Tikur Anbessa hospital was taken from the patients’ files. For these patients the additional worst-case scenario analysis was performed with assumption of dead after 6 months of last follow-up date registered on their medical record  . The tep values less than 0.05 were considered significant. All data were analyzed using SPSS 20.0  and R 3.4.2. (R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.)The primary end point of this study was overall survival. Groups are compared using parametric (t test) and nonparametric  tests. Kaplan-Meier curve and survival analysis was performed using Log-rank test to assess significant differences between groups regarding survival. All The ethical clearance was obtained from the Ethical review committee of the Radiotherapy unit of Tikur Anbessa Hospital under Addis Ababa University College of Health Sciences (AAU CHS). Informed consent was waived by the same ethics committee that approved the study, considering the study was mainly based on the retrospective record analysis.Three hundred forty-nine cervical cancer patients received radiotherapy in Black Lion Hospital in 2014. Of those, 242 patient files could be retrieved. The median age at diagnosis was 48 years (range 27 to 86). The average number of births they gave was 5.62 (±2.88). HIV was relatively the commonest comorbidity, in which 26 (11%) were found to be positive (Table p < 0.001). The waiting time for receipt of RT also differed by stage. The number of patients who received RT with 3 months were 13 (15.1%), 38 (44.2%) and 35 (40.7%) for stage I/II, III and IV, respectively (p < 0.001).Most of the patients had no surgery for cervical cancer prior to their presentation to radiotherapy center; only 26 (11%) patients underwent surgery. The median waiting time for radiotherapy was 5.6 months (range 2 to 9 months). During the waiting time, 31 (13%) patients showed stage migration from their baseline at the first oncologist consultation. There was a difference in waiting time for initiation of RT based on the stage and intent of treatment. About 55 patients (60.4%) s treated with palliative intent received RT within 3 months after diagnosis, while only 31 patients (20.5%) received RT within 3 months in curative intent groups (Thirty-four 14%) patients received concurrent chemotherapy with radiation while the remaining (majority of) patients received radiation therapy alone. Most of the patients were had lost from follow-up in Tikur Anbessa hospital before 1 year  were known dead while 102 (42.1%) patients were alive or censored. For worst-care scenario we estimated that patients had died 6 months after their last follow up if they were not responding on telephone calls. This results in 184 (76%) deceased, while 58 (24%) were known alive within 6 months before the study closure date.The estimated 60 months (5 year) overall survival probabilities were 28.4% (SE 4.0) in the main analysis. The one-year, two-year, three-year and four-year overall survival probabilities were 77% (SE 2.8), 45.3% (3.5), 36.0% (SE 3.4) and 32.2% (SE 3.5), respectively. The median overall survival time was 23.0 months (95% CI 18.5–27.5).However, in the worst-case scenario the 60 months (5 year) overall survival probability reduced to 20.5% (SE 3.2) and the median overall survival to 18 months (95% CI 15.6–20.3). The one-year, two-year, three-year and four-year overall survival probabilities were 74.3% (SE 2.8), 35.2% (SE 3.1), 27.2% (SE 2.9) and 24.4% (SE 2.9), respectively.p < 0.001) in main analysis  months. The estimated median time of survival based on the stage at the initiation of radiotherapy was, 19.0 (95% CI 13.4–24.6) and 14.0 (95% CI 9.2–18.8) months for stage III and IV, respectively (p < 0.001) in main analysis . The median survival for stage I/II groups is 52 months, but no confidence interval can be calculated. The mean survival for this group is 40.7 (95% CI 35.9–45.4%) months. The estimated median time of survival based on the stage at the initiation of radiotherapy declined to 17.0 (95% CI 14.7–19.3) and 12.0 (95% CI 9.2–14.7) months for stage III and IV, respectively (p < 0.001). In the worst-case scenario the median survival time was 28.0 (95% CI 20.9–35.0) and 12.0 (95% CI 10.3–13.7) months for patients treated as curative and palliative intent, respectively (p < 0.001)  and 13.0 (95% CI 11.2–16.7) months for patients treated with curative and palliative intent, respectively in main analysis group  were substantially lower than those reported in previous studies in TAHRC. Kantelhardt et al. reported a one-year and two-year survival rates of 90 and 74% , respectively . SimilarIn general, our survival findings are 15–25% lower than those reported in high income countries such as the United States and in some countries in Africa  in part Concomitant chemo-radiotherapy for locally advanced cancer patients has become standard of care since the late 1990s, after several study documented the survival benefit of this therapy compared to radiotherapy alone –20. The In addition to sub-standard treatments, the low survival rate of cervical cancer patients in our study in part reflects late stage presentation, as is the case in many sub-Saharan African countries , 21, 22.A strength of our study is it showed long-term survival probability of cervical cancer and the predictors for survival in Ethiopia. It also showed the impact of longer waiting time on the overall treatment outcome. It can also help as the reference for the assessment of success in various actions taken to improve access to care. Limitations of our study include missing information  for many patients and lack of regular follow up after radiotherapy. Our findings of survival rates may be affected by loss to follow-up or ascertainment bias. We did not also have data on radiotherapy dose and schedules, adherence to treatments, general health performance, and nutritional status, which all influence survival.The survival of cervical cancer patients in Ethiopia (treated in TAHRC) remains low because of late stage presentation, suboptimal treatments (lack of brachytherapy), and disease progression while waiting for radiotherapy. These findings underscore the need for concerted, multisectoral efforts to improve early detection access to timely and high-quality radiotherapy services.


Bacillussp. strains were isolated from agricultural soils of Turkey. The potent extracellular lipase producer was selected. It was identified by 16S rRNA, named asBacillus cereusATA179. Optimal nutritional and physical parameters for lipase production were determined. Sucrose as the carbon source, (NH4)2HPO4 as the nitrogen source, CaCl2 as the metal ion were obtained. The best results of physical parameters were stated at 45°C, pH 7.0, shaking rate 50 rpm, inoculation amount 7% and inoculum age 24 h. ATA179 strain showed a 51% increase in enzyme production in the modified medium created by optimizing nutritional and physical conditions. Optimum pH value and temperature were found as 6.0 and 55 °C, respectively. CaCl2, Tween 20, Triton X-100 had an activating effect on enzyme activity. Vmax and Km kinetic values were found as 18.28 U/mL and 0.11 mM, respectively. The molecular weight was determined as 47 kDa. Lipase was found to be stable up to 75 days at -20 ºC. The potential of the enzyme in detergent industry was also investigated. It was not affected by detergent additives, but was found to be effective in removing oils from contaminated fabrics. This new lipase may have potential to be used in detergent industry.In this study, 341 Enzymes, which have important metabolic functions for cellular structures, have entered daily and economic life to be used for various purposes. Industrial use of enzymes has become widespread since 1960s . The most important enzymes used in the industry are amylases, proteases, lipases, and phytases. Lipases are enzymes that break down the glycerol esters of fatty acids . They are a physiologically and commercially important group of enzymes as their use increases rapidly and steadily for various biotechnological applications . The uses of microbial lipase market is estimated to be USD 425.0 million in 2018 and it is projected to reach USD 590.2 million by 2023, growing at a CAGR of 6.8% from 2018 . In general, lipases have promising applications in detergent formulation, organic chemical processing, agrochemical industry, biosulfonate synthesis, food, pharmacy, cosmetics, and paper manufacturing . Lipases are used in both dishwashing and laundry formulations commercial detergents for the removal of lipid stain, sebum, and fatty food stains from fabrics. Approximately 32% of the microbial lipases produced in the world are used in the detergent industry as it forms the very important compound in detergents . The use of lipases in the detergent industries is increasing day by day.Pseudomonas auroginosaandSerratia marescensspecies in the year 1901 .Achromobacter, Alcaligenes, Arthrobacter, Bacillus, Burkholderia, Chromobacterium,Geobacillus, andPseudomonas genera are important sources of bacterial lipase .Bacillus species have an important place among bacteria. SomeBacillusspecies have thermostable lipase production. Thermostable lipases are preferred in the industry . Approximately 96% of enzymes used for industrial purposes are produced from microorganisms . In the industry, mostly bacteria and fungal lipases are preferred. Bacterial lipases were first observed in the strainsThe first stage of enzyme production by microbial route is the selection of microorganism at nature. Culture media and fermentation conditions are also important parameters affecting enzyme production. In addition, it is important to reveal the properties of enzymes obtained from new isolates by purification .Bacillusstrains, optimization of growth conditions, characterization by partial purification, and its potential in the detergent industry were investigated.In this study, the screening of lipase enzyme production capacities from previously isolated 341White fabrics (50% polyester (PES) + 50% cotton) were obtained from Bursa Uludag University, Department of Textile Engineering. The pollutants (olive oil and grease) and different branded detergents (3 solids and 3 liquids) used in the study were purchased from markets.Bacillussp. strains that were obtained from our previous studies were used  TheBacillussp. strains were screened for lipase production and cultivated on TBA (Tributyrin Agar) solid medium containing (g/L) meat extract 3, peptone 5, tributyrin 10 mL, and agar 20 (pH 7.0) at 37 oC for 48 h . After incubation, colonies forming clear zone on the petri dish were accepted as positive for lipase. The diameters of the colony and the hydrolysis zones around colonies were measured by ruler. The following formula was used for calculating the Enzymatic Index (EI) .In this study, 341EI = Diameter of hydrolysis zone (1) Diameter of colonyThe strain showed the largest EI value was chosen and assays were continued with this strain. Bacillus genomic DNA was extracted for the bacterial identification and phylogenetic analysis . The sequence analysis was performed using ABI 3100 Genetic Analyzer . The obtained sequences were compared with those desosited in the GenBank database  using BLAST . The 16S rRNA sequences of strain was aligned with otherBacillus species using CLUSTAL W program . The phylogenetic analysis was done by MEGA 6.0 software, using the neighbor-joining method . The sequence was submitted to genbank and accession number was obtained.Bacteria identification and phylogenetic analysis were carried out by REFGEN Biotechnology  company.To determine the best enzyme production, three different media  were used and compared with each other. Among the culture media, Kumar et al. (2005) medium exhibited a significant impact on enzyme production. This medium contained (w/v %) yeast extract 0.5, peptone 0.5, CaCl2 0.005, NaCl 0.05, olive oil 1 (pH 7.0). Overnight precultures adjusted at 1 × 108 CFU/mL were inoculated at 5% in medium and incubated at 37 °C for 72 h in 150 rpm. Bacterial growth and enzyme activity were performed at the 16th, 24th, 40th, 48th, 64th, and 72th hours. The optical density at 600 nm of bacterial growing was followed by a spectrophotometer (Beckman Coulter-UD 700).2, 1 mL of olive oil and 1 mL of crude enzyme solution were incubated in a water bath shaker (150 rpm) at 30 °C for 30 min. The enzymatic reaction was stopped by the adding 20 mL of 99.8% ethanol. The pH value of the incubation medium was titrated to 10.5 using a burette containing 50 mM KOH. One unit lipase activity was described as the amount of enzyme releasing 1 µmol of fatty acid under experimental conditions.Lipase activity was assessed by titrimetric analysis . Reaction mixture containing 4.5 mL of 50 mM Tris-HCl (pH 7.0), 0.5mL of 0.1 M CaClBacillussp. Various carbon sources (1%) such as castor oil, coconut oil, corn oil, glucose, maltose, sucrose, starch, soybean oil, sunflower oil, and olive blackwater waste evaluated.In this study, nutritional and physical parameters were optimized for production of lipase by4)2HPO4, KNO3, (NH4)2NO3, (NH4)2SO4 as inorganic nitrogen sources were used. The effect of different metal ions (0.055%), such as MnSO4, FeSO4, LiSO4, BaCl2, KCl, NaCl, CaCl2, CuSO4,were studied for this purpose. For the physical optimization of the medium, different temperatures (35-60 °C), pH ranges (4.0-9.0), inoculum amounts (5%-10%), inoculum ages (18-48 days) and agitation (0-250 rpm) were investigated.As organic nitrogen sources (1%) on enzyme production yeast extract, corn step liquor, peptone, tryptone, and , dissolved in 50 mM Tris-HCl buffer (pH 7.0) containing 1 mM CaCl2 and then dialyzed overnight in the same buffer at 4 οC. After dialysis, samples were concentrated using ultrafiltration through a Centriprep-10 concentrator (Amicon). Lowry et al. (1951) method was used to determine the protein content.The crude lipase enzyme from4, MnSO4, MgSO4, ZnSO4, CuSO4, CaCl2, NaCl, LiSO4, BaCl2, KCl, EDTA, SDS, Tween 20 and Triton X-100 Tween 20 were used. Relative activities (%) were calculated taking the untreated enzyme activity noted as 100%.To determine the optimum temperature, enzyme was incubated between 30–80 °C. The optimum pH of enzyme was determined by using some buffers; 0.1 M glycine-HCl (pH 2.0 and 3.0), 0.1 M sodium acetate (pH 4.0-6.0), 0.1 M Tris-HCl (pH 7.0 and 8.0) and 0.1 M glycine-NaOH (pH 9.0 and 10). Temperature and pH value stability were also tested. To detect the effect of metal ions, salts and reducing compounds on enzyme activity, 1 and 5 mM FeSOm and Vmax were calculated from the Lineweaver-Burk plot. The molecular weight of the enzyme was estimated by SDS-PAGE. To determine the storage temperature of the crude lipase, enzyme was stored at room temperature, 4 °C and –20 °C upto 105 days, and the residual activity was calculated at each 15 days. For kinetic analysis, tributyrin concentration was ranged from 0.1–1.2 mM and enzyme activity was assessed K2O2 at 55 and 65 oC for 1 h at 100 rpm. The change in lipase activities was calculated as relative activity (%) based on the initial activities.To examine the effect of detergent additives on lyophilized lipase activity, the enzyme was incubated with 1 and 5% Triton X-100, EDTA, SDS and H×60 mm, and contaminated separately with olive oil and grease oil to cover the fabric. The fabrics treated were incubated at 37 ºC for 1 h in 90×90 mm diameter petri dishes by applying the above conditions. After incubation, the fabrics were gently rubbed with a brush and rinsed with distilled water and dried. Contaminated fabrics were treated with lipase enzyme and detergents and whiteness indexes after enzyme, and detergent applications were measured using Konica Minolta CM3600-D color measurement spectrophotometer. Uncontaminated fabric was used to standardize the color measurement spectrophotometer. The “whiteness” indexes of the control and treated samples were compared. For lipase application, a white fabric containing 50% cotton and 50% polyester (PES), was used. Olive oil and grease oil were taken to trial as contaminants. Detergents available in the market (3 solids and 3 liquids) were selected from different brands to be tested. The experimental study was done as follows: contaminated fabric (control), contaminated fabric + 1 mL of lipase, contaminated fabric + 1 mL solid detergent, contaminated fabric + 1 mL solid detergent + 1 mL lipase, contaminated fabric + 1 mL liquid detergent, and contaminated fabric + 1 mL liquid detergent + 1 mL lipase. The fabric pieces were cut to a size of 60Statistical analysis of experimental results was performed using student’s t-test that was calculated using excel spread-sheets available in Microsoft Excel. Results are the means of three independent determinations and bars correspond to standard deviations.Bacillusstrains used in the study, 141 of them were obtained as potential extracellular lipase producer. Of these 141 strains 74 displayed weak (EI = 0.07–0.30), 42 medium (EI = 0.30–0.50) and 25 large hydrolytic zones (EI = 0.5–2). One strain with EI = 2 was selected . Three hundred and forty-oneBacillus cereusbased on 16S rRNA sequence similarly . The partial 16S rRNA of the isolate ATA179 was deposited in GenBank (accession number MW699624). It was namedB. cereus ATA179.Isolate was identified asThe maximum enzyme production of ATA179 was obtained with 6.6 U/mL at 48 h in the medium of Kumar et al. (2005) . The maximum biomass reached after 40 h cultivation.Ten carbon sources were tried for lipase production. The best one was sucrose (8 U/mL). An increasement of 21% in lipase production was achieved compared to the control medium. The carbon source preference ranking of ATA179 in terms of enzyme production was as follows; sucrose > maltose > glucose > starch > coconut oil > olive blackwater = control (olive oil) > sunflower oil = soy oil = castor oil > corn oil . Maximum bacterial growth was as follows; sunflower oil> starch = soy oil = coconut oil> glucose = sucrose = maltose = castor oil> corn oil = control> olive blackwater .4)2HPO4 as the inorganic source. The enzyme yield was 86% compare to the control medium. In addition, enzyme yield was achieved with 74% (NH4)2NO3 and 59% (NH4)2SO4. Organic and inorganic nitrogen sources preference in terms of enzyme activity ofBacillus cereusATA179 were (NH4)2HPO4 > (NH4)2NO3 > (NH4)2SO4 > yeast extract > peptone > tryptone = control > corn steep > KNO3 . Inorganic sources were found to be more effective than organic sources but the least enzyme activity was observed with KNO3. The maximum bacterial growth was as follows: corn steep > yeast extract = tryptone = control > (NH4)2HPO4 > peptone = (NH4)2SO4 > (NH4)2NO3 > KNO3 medium . Effect of various nitrogen sources on lipase production was tested. The results showed that the best production was determined as 12.3 U/mL in the presence of (NH2 (8 U/mL) was found to be the best metal source , and an enzyme yield of 21% was obtained. All metal ions have been found to be equally effective. When CaCl2 and NaCl in the control medium were taken separately, CaCI2 was found to be more effective alone.The effect of different metal ions was assessed. CaClSome physical factors  were studied for its influence on lipase production by ATA179. In the study, it was determined that the maximum enzyme production was at 45 °C . However, biomass was found to be low at the same degree. Various pH values were tested and maximum enzyme production was reached at pH = 7.0 . No growth was observed at pH = 4.0. While more growth was detected at high pH, decreases in enzyme production were determined. The optimum agitation rate for lipase production was 50 rpm . While there was a gradual decrease in enzyme production with increasing agigation rates, an increase in growth was observed. Obtained results showed that the optimum inoculum amount for maximum lipase production was 7 %. . Bacterial growth remained almost stable. In this study, the maximum enzyme production was obtained with 24 h culture as inoculum age . Bacterial growth and enzyme production decreased with increasing age of inoculation. B. cereus ATA179 strain. The modified medium contains 1% sucrose, 1% (NH4)2HPO4 and 0.055% CaCl2. This medium was inoculated at a rate of 7% from the culture whose inoculation age was 24 h and the production was carried out at 45 °C, pH = 7.0, 50 rpm for 48 h. The enzyme activity was determined as 10 U/mL. An enzyme yield of 51.5% was obtained compared to the control (6.6 U/mL) medium. There was also an increase in bacterial growth.In this study, a new production medium was developed by optimizing nutritional and physical factors for lipase fromB. cereusATA179 are summarized in Table 1. The purity was checked by SDS-PAGE, and the molecular weight was estimated at 47 kDa . Partial purification of lipase was realized with ammonium sulphate precipitation (70%). After dialysis, the enzyme was partially purified by ultrafiltration. The lipase was 7.2 fold partially purified, and obtained in a 5.7% yield. Specific activity was 36.5 U/mg. The results of partial purification of lipase fromBacillus cereusATA179 was 55 ºC . Thermostability studies have shown that the activity of lipase was retained at 90% at 55 °C for 50 min . Therefore, it may be a thermostable enzyme. As seen in Figure 9c, it was determined that the optimum pH value of the enzyme was 6.0. While it was determined that the enzyme has high activity in acidic side, decreases in activity were observed in alkaline side. When the pH stability was investigated, it was found that it remained active (94%) for 60 min at pH = 6.0 .The optimum temperature for the lipase activity from2, MnSO4 and BaCl2stimulated lipase activity at both 1 and 5 mM concentration. Overall, the metal ion concentration of 1 mM was found to be more effective than that of 5 mM. NaCl and KCl showed an inhibitory effect. The lipase activity was activated by Triton×100 and Tween 20, inhibited by EDTA and SDS . The Km and Vmax of lipase fromB. cereus ATA179 were calculated as 0.11 mM and 18.2 U/mL, respectively .The effects of some potential compounds on enzyme activity were studied to find out which one of them were inhibitor or stimulator. CaClThe enzyme remained more stable at –20 °C in the experiments made to determine the storage temperature. After 105 days, the enzyme retained 81% of its initial activity. The activity of the enzyme was almost preserved upto 60 days at room temperature (RT) and 4 °C .2O2 were added at 1% concentrations, and the lipase enzyme was incubated with these detergent additives for 1 h at 100 rpm, 55 and 65 °C. According to the initial activity of the enzyme, as seen in Table 2, enzyme activity increased 22% in the medium containing 5% SDS at 65°C.The stability of the lyophilized lipase in the presence of various oxidizing agents and surfactants was checked to determine the potential of the lipase in the detergent industry. Triton X-100, EDTA, SDS and HThe potential effect of lipase enzyme on fabrics contaminated with olive oil and grease oil was investigated. According to the results, the whiteness index of only olive oil and grease oil contaminated fabrics was obtained as 66.6 and 65.4, respectively. In the experiment where only lipase was used, the whiteness index was 94 in olive oil fabric and 92.9 in grease oil fabric . As compared to the measurements made after applying lipase, 41%–42% whiteness index was detected. This has shown that the lipase enzyme is effective. In both pollutants, when lipase is combined with solid and liquid detergents, it has been observed that it has good interaction with some detergents and less effect in some. The less effective effect of enzyme combined with some detergents may be due to the chemical formulation of detergents as the additives contained in detergents may have reduced the enzyme’s activity. In this study, the best effect of lipase enzyme was obtained when used with L1 detergent on grease oil. The whiteness indices of liquid detergent (L1) in fabrics contaminated with olive oil and grease oil were determined as 128.5 (93% yield) and 114.5 (75% yield), respectively. If this detergent was used together with lipase enzyme, it was determined that the result would be 131 (97% yield) and 126 (93% yield), respectively. But in general, lipase was effective in the presence of solid detergents . Industrial enzymes have gained importance due to the diversity of their usage areas and their high economic value. Since each industrial application needs enzymes with specific features, the microorganisms that produce these enzymes must be isolated from nature. Among these enzymes, lipases have a wide range of applications in the pharmaceutical , food, and detergent industries .Bacillussp. strains isolated from soil samples were screened qualitatively and lipase potential of 141 strains from 341Bacillussp. strains were determined. Among them, theBacillus sp. strain with the highest lipase production was identified at the species level by 16S rRNA sequence analysis and was namedBacillus cereusATA179. In this study, lipase capacities byBacillusspecies, maximum production was obtained at different hours. It was achieved at 16 h forB. thermocatenulatus, at 12 h forBacillusRSJ1  , whileBacillusstrain,B. cereusandB. coagulanshad maximum lipase production at 72 h , and at 60 h forBacillus methylotrophicusPS3 . Chakraborty and Raj (2008) obtained maxima lipase production byB. licheniformisMTCC 6824 after 48 h incubation. It was reported that the highest lipase production was in the logarithmic phase, the end of the logarithmic phase, or the stationary phase.Since the promotion of lipase enzyme production depends on the nutrients in the medium where the bacteria are place, 3 different media were used and the best medium for enzyme production was determined. The new isolate showed the highest lipase production after 48 h incubation (6.6 U/mL). The highest growth was obtained at 40th h. It was determined that the maximum enzyme production was in stationary phase. In other studies with different4)2HPO4 with a yield of 86%. Enzyme yield was achieved by 74% with (NH4)2NO3, 59% with (NH4)2SO4 and 7.5% with the organic nitrogen source yeast extract. Among the nitrogen sources, inorganic sources other than KNO3 were more effective than organic sources. This can be due to the positive interaction of ammonium salts with other components in the medium. Some metal ions are an important factor affecting enzyme production because they act as stimulator. In the study, CaCl2 was more effective, followed by BaCl2 and LiSO4 to determine the effect of metal ions. MnSO4 andNaCl ions has the lowest ability of enzyme production. CaCl2 and NaCl, which are found together in the basal medium, has been tested separately, CaCl2 showed a 21% increase in enzyme production when used alone. The presence of more than one metal ions in the medium may have a unfavorable action on production. The content of the culture medium and fermentation conditions are important factors affecting enzyme production. The culture media has a striking effect as it stimulates enzyme production. Since lipases are inducible enzyme, they are significantly affected by lipid, carbon, and nitrogen sources. In this study, nutritional factors were assessed, the best carbon source was sucrose and enzyme production increased by 21% compared to basal medium. While enzyme production increased in the presence of maltose, glucose and starch, it was not stimulated in the presence of lipid sources. Among nitrogen sources, the best was inorganic nitrogen source . In this study, the cultivation was carried out at different inoculum amount (5%–10%). The optimum inoculum amount was found to be 7%, as compared to 5% inoculum used initially and showed a 4.5% increase in production. An optimum inoculum amount will be suitable for bacterial growth in an medium with sufficient oxygen and nutrients. It was found that the increase of the amount of inoculation was not effective on enzyme production. Influence of inoculum age on lipase production was investigated. The inoculation age at which the maximum enzyme production was obtained was determined as 24 h. An increase of 10.6% has been achieved compared to the control. The use of old cultures as inoculum caused a decrease in production which may be due to the old cultures late adapting to the medium. In this study, a new modified medium was created by combining the best nutritional and physical parameters for the production of high amounts of lipase from the new ATA179 isolate. In this new medium 51.5% lipase production was achieved compared to basal medium.Physical factors are as effective as nutritional factors in enzyme production. The lipase production byThe age of inoculum is highly variable depending on the process, cultivation conditions, medium composition and the microorganism, among other factors. Moreover, the inoculum amount was an important factor in an experimental design to obtain high enzymatic activity .BacillusMPTK 912 were glucose, peptone, Fe2+ and Mg2+, pH 8.0 and temperature 35 °C. Sirisha et al. (2010) stated that peptone was the best nitrogen source for lipase production. Similar to our result, Dong et al. (1999) reported that inorganic nitrogen sources (NH4Cl and (NH4)H2PO4) were more efficient. Bacha et al. (2016) noted that xylose and yeast extract were the best sources of carbon and nitrogen for lipase production fromS. aureus. Many researchers have reported that glucose has different effects. While glucose stimulates lipase production inB. licheniformisH1,Bacillus sp. GK 8 and SB-3 ,B. alcalophilusB-M20 , B. megateriumAKG-1 , Bacillus.sp. L2  andB. subtilis strains have been found to inhibit lipase production. On the other hand, lipase production fromBacillusstrains was induced by fats but its expression was stimulated by sugars and sugar alcohols, especially galactose, lactose, glycerol, and mannitol . In our study, it was found that enzyme production was not high in the presence of fats. Oil hydrolysis products may have had a negative effect on lipase production. However, olive oil and yeast extract was found to be most effective on lipase production fromAspergillus niger. Optimum physical parameters were 24 °C, pH = 7.0, 200 rpm and 72 h .Various researchers have investigated the effects of nutritional and physical factors on lipase production and reported different or similar results. Lipase production was stimulated with 2% starch and olive oil. Maximum enzyme production conditions were found to be 37 °C, neutral pH and 24 h incubation . Kumar et al. (2012) reported that the best nutritional and physical factors for lipase production fromBacillus thuringiensis(TS11BP) was at pH = 8.0, 45 °C, 96 h with 14% inoculum amount. Dextrose as carbon source and beef extract as nitrogen source were reported . Pallavi et al. (2014) stated that starch and peptone were the best sources forBacillus subtilisY-IVI strain. Mazhar et al. (2017) reported that the maximum lipase production fromB. subtilisPCSIR-39 was achieved in the presence of sucrose. They found that peptone was the best nitrogen source. They reported that Ca2 + and Mg2+ had good stimulating effect on enzyme production, 45 °C was the best temperature and optimal pH value was 7.0, 5% of inoculum. Niyonzima et al. (2013) optimized the lipase production environment forBacillus flexusXJU-1. They achieved maximum lipase production in 36 h, at 37 °C, pH = 11.0, 2% inoculum amount, when they used refined yeast extract as the best nitrogen source and cottonseed oil as the best carbon source. WhileBacillusL2 lipase production was totally inhibited by Mg2 + ions, the addition of Ca2 + and Fe3+ resulted in high lipase production .B. alcalophilusB-M20 can tolerate salinity up to 7.5 %, but high NaCl and KCl concentrations inhibit lipase production .The best lipase production fromStaphylococcus hominisMTCC 8980 were found to be 33.1 °C, 7.9, and 178.4 rpm, respectively . While maximum lipase production from theBacillussp. strains is achieved at pH = 6.0 and 37 °C , Larbidaouadi et al. (2015) have achieved it at pH = 8.0 and 40 oC (1.5 U/mL). Iftikhar et al. (2003) reported the amount of inoculum as 3.0%. Sekhon et al. (2006) stated the range of 6.5-8.0 as the enzyme production pH value. InBacillus tequilensisNRRL B41771 , 1% inoculum amount has been reported for optimal lipase production. In contrast,Bacillus pumilushas a 10% higher inoculation amount for maximum lipase production . Kumar et al. (2005) have prepared a new modified medium forBacillus coagulansBTS-3. In the combination of peptone and yeast extract as nitrogen sources and mustard oil as carbon source at pH = 8.5, 55 °C and 48 h, enzyme activity was determined as 1.16 U/mL. Abbas et al. (2017) reported that maximum lipase production (12.81 U/mL) from Bacillus subtilisPCSIR NL-38 was obtained with NH4NO3, glucose, and FeSO4.7H2O at pH = 7.0, 40 °C, 7% inoculum amount and 48 h of incubation. In the study withBacillus subtilis, lipase production reached a maximum at 30 °C with 84 h of fermentation (4.72 U/mL). They obtained a new modified medium, and lipase activity was determined as 4.96 U/mL in the presence of 5% inoculum amount, 0.5% yeast extract, 0.25% olive oil and 10 mM Ca2 + . The optimal temperature, pH value ,and agitation rate ofAs seen in results of studies, the fact that the differences in lipase production yields with different microorganisms can be result of bacterial strain characteristics as well as the culture medium cultivation and composition conditions. In addition, different results can be obtained in measuring the lipolytic activity due to experimental conditions. In studies that investigate the effects of physical and nutritional factors on lipase production, different results show that the metabolic pathways used by microorganisms are different.In this study conducted to determine the potential of lipase use in the detergent industry, it was found that lyophilized lipase preserved its stability with oxidizing agents and various surfactants. On the other hand, in determining the effect of lipase enzyme on fabrics contaminated with olive oil and grease oil, the whiteness index measurements showed positive results on the removel of contamination. Our results suggest that the lipase from new isolate ATA179 may have potential in the detergent industry.Authors declare that they have no conflict of interest and procedures including human and/or animal subjects.