Phvul.001G214500, Phvul.007G229300 and Phvul.010G142900.1 on Pv01, Pv07 and Pv10, respectively. These results indicate that GWAS-based QR was able to enhance the understanding on genetic architecture of phenological traits (DFF and DTF) in common bean.Flowering is an important agronomic trait. Quantile regression (QR) can be used to fit models for all portions of a probability distribution. In Genome-wide association studies (GWAS), QR can estimate SNP (Single Nucleotide Polymorphism) effects on each quantile of interest. The objectives of this study were to estimate genetic parameters and to use QR to identify genomic regions for phenological traits  in common bean. A total of 80 genotypes of common beans, with 3 replicates were raised at 4 locations and seasons. Plants were genotyped for 384 SNPs. Traditional single-SNP and 9 QR models, ranging from equally spaced quantiles (τ) 0.1 to 0.9, were used to associate SNPs to phenotype. Heritabilities were moderate high, ranging from 0.32 to 0.58. Genetic and phenotypic correlations were all high, averaging 0.66 and 0.98, respectively. Traditional single-SNP GWAS model was not able to find any SNP-trait association. On the other hand, when using QR methodology considering one extreme quantile (τ = 0.1) we found, respectively 1 and 7, significant SNPs associated for DFF and DTF. Significant SNPs were found on Pv01, Pv02, Pv03, Pv07, Pv10 and Pv11 chromosomes. We investigated potential candidate genes in the region around these significant SNPs. Three genes involved in the flowering pathways were identified, including  Phaseolus vulgaris L.) is the world’s most important grain legume for human consumption T represents the unknown parameters.Prior to performing genome-wide association (GWA) analyses, the genetic structure of the populations used in this study was assessed by principal component analysis (PCA) using the ion in R . PCA wasθτ) by solving the following optimization problem:τ(·) is denoted as a check function [The SNP effects were estimated at different portions of a probability distribution of the traits by quantile regression . This mefunction , and is 10P) of 3.88 and 4.58 were calculated based on the Bonferroni method for multiple testing to identify SNPs significant at 5% and 1%, respectively.The markers effects were also obtained using the traditional GWA approach, by fitting one SNP at a time . Thresholds  and ranges of the phenological traits are presented in P<0.01) for all 3 traits , and the genotype dispersion based on the first two PCs are presented in P>0.1x10-4) associations between SNPs and phenological traits . The Manhattan plots for DFF, DTF and DEF are showed in Association between SNPs and (adjusted) phenotypes were performed using traditional single-SNP and quantile regression (QR) methodologies. The traditional single-SNP approach did not result in any significant (P<0.1x10-4) using the lowest quantile (τ = 0.1) evaluated in this study (P<0.1x10-4) for DFF  SNPs were identified on Pv01 (scaffold00005_1715227), Pv02 (scaffold00020_86873), Pv03 (scaffold00083_261143), Pv07 (scaffold00028_145636), Pv10 (scaffold00036_329244), and Pv11 (scaffold00007_368524). Altogether, these SNPs explained 12.5% of the variability in DTF (P > 0.1x10-4).The location of these SNPs are shown in y in DTF . One of After that, we investigated potential candidate genes in the region around these significant SNPs . Three gHeritability estimates for DFF (0.58), DTF (0.49) and DEF (0.32) were consistent with those reported in the literature. Specifically, for DFF and DTF, estimates were close to those reported by , with 0.In this study, we aimed to enhance the understanding of the genetic architecture of phenological traits  in the common bean under a QR approach. The proposed method allows investigating the relationship between explanatory variables (i.e. SNPs in our study) and phenotype at different portions of a probability distribution of the traits, which resulted in more informative results by taking into account the extreme tails of trait distributions. QR uses the same principle used in sampling from the extremes of the trait distribution , 9, 10, Although the main objective of this manuscript was just to introduce the QR for plant breeders under a GWAS approach, we believe that this concept can be better exploited under a small sample size framework. The fact of QR take into account any quantile of phenotypic distribution can be considered as a robust tool to make inference in the presence of small population size. Although selective samples (sampling from the extremes) have been effective for QTL detection , under aPhvul.001G221100, located on Pv01, as a candidate gene for controlling photoperiod sensitivity and flowering in common bean. Moghaddam et al. [Phvul.001G064600, Phvul.001G192200, Phvul.001G192300, and Phvul.001G087900 with potential role on days to flowering, because of their function on regulates Flowering Time [The number of reports including GWAS for economically relevant traits in the common bean is still very limited. Kamfwa et al. , using 2ing Time ; change ing Time ; suppresing Time ; regulatIn the present study, no associations were found when analyses were performed using traditional GWA (single-SNP GWAS) methodology. The lack of associations using this methodology was expected because of the limited power of this study, which is limited due to the small number of markers and population sizes available . HoweverPhvul.001G214500, located on Pv01 (~50Mb). The functional annotation on Phytozome indicated that Phvul.001G214500 is a flowering time control protein FCA-related. This protein plays a role in the regulation of flowering time in the autonomous flowering pathway by decreasing expression levels of flowering locus C [Phvul.007G229300, which was located on Pv07 (~47Mb), is classified as protein terminal flower 1. A BLASTn search on NCBI data resulted in a best score to a gene TFL1z. Flowering time (FT) acts in part downstream of transcription factor gene, Constans (CO), and mediates signals for flowering in an antagonistic manner with the TFL1 gene. Phvul.010G142900.1 that is mapping near the Pv10 (~41Mb) is a protein early flowering 3 [Among the significant SNPs, 2 located on Pv01 and Pv07 are closest (<3.5Mb) to 2 genes involved in the flowering pathways. The first one,  locus C . Accordiwering 3 . This prwering 3 . The repIn general, these results indicate that using quantile regression to perform GWAS for flowering traits in the common bean resulted in the identification of QTLs. In contrast, this was not the case for when we used traditional single-SNP analyses. Indeed, these results are reasonable, once QR allows the estimation of effects for all portions of a probability distribution of the trait, using of the same principle used in sampling from the extremes of the trait distribution, increase the statistical power of the analysis , 9, 10. Quantile regression-based GWAS was able to detect true QTL for phenological traits (DFF and DTF) in the common bean that were missed when using traditinal single-SNP. The associations were identified using one extreme quantile (τ = 0.1), using the same principle used in sampling from the extremes. Finally, genomic regions identified in this study were enriched with candidate genes involved in the flowering pathways.S1 Table(PDF)Click here for additional data file.S1 Fig(A) Scree plot and variance explained (%) by each component. (B) Plot for PC1 against PC2 illustrating the population structure of 80 common bean genotypes.(TIFF)Click here for additional data file.S2 FigThe solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.(TIFF)Click here for additional data file.S3 FigThe solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.(TIFF)Click here for additional data file.S4 FigThe solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.(TIFF)Click here for additional data file.S5 FigResults are sorted by quantile (τ), from 0.1 (A) to 0.9 (I). The solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.(TIFF)Click here for additional data file.S6 Figτ), from 0.1 (A) to 0.9 (I). The solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.Results are sorted by quantile ((TIFF)Click here for additional data file.S7 FigResults are sorted by quantile (τ), from 0.1 (A) to 0.9 (I). The solid and dashed lines show the Bonferroni-adjusted thresholds of 3.88 and 4.58 for alpha equals to 5% and 1%, respectively.(TIFF)Click here for additional data file.


Although there are multiple corrections to both formatting and some content in Tables and Figures, and some minor changes to reported results and analysis, none of these corrections alter any major findings, discussions or conclusions from the initial study.$” values in row L are incorrect. Please see the corrected There are a number of errors in There are multiple errors in There are a number of errors throughout the article. In the Abstract, the first sentence of the Results section should read: Fourteen radiology departments (15 ED) provided 7075 CTPA data (94% ≥64-slice CT); PE were reported in 1033  with four sites significantly below and one above the 15.3% target.The first two sentences of the “Site demographics /characteristics” section of the Results should read: Fourteen reporting sites  provided consecutive data for 7075 ED ordered CTPAs. Numbers ranged from 324 to 1056 CTPA per site, over 8 months to 2 year periods (from 01/2012 to 02/2015), with the exception of site F which provided consecutive data from twelve years of CTPA use (from 2002), due to lower usage rates in a smaller adult ED population.The second paragraph of the same section should read: Of the 7062 CTPA with complete demographic data, 3870 were performed in females , p<0.001 for difference of 9.6% (CI 7.95–11.25%)) and the mean age was 60.0 years . Yield was significantly lower amongst females  than males ; p < 0.0001 for difference in proportions. The mean age of those with a positive scan was 61.5 (SD = 15.6) vs. 59.7 (SD = 16.7) years for negative scans (p <0.001 for difference).The paragraph of the “SSPE/ small PE.” section of the Results should read: The last sentence in the “Other potentially important correlations/ associations” section of the Results should read: There was however a positive linear correlation  between rates of CTPA usage and rates of PE diagnosed per 1000 adult attendances.The first sentence of the second paragraph in the “Key findings” section of the Discussion should read: The overall proportion of SSPE was 8.8%, ranging from 2.0–15.9% of all PE diagnosed, but the more inclusive small PE grouping found no significant variation (10.2–21.1%).The fourth sentence of the “Comparison of key findings with previous literature” section of the Discussion should read: Our study found yields occasionally dropped just below 10% (2/14 sites), but 50% of sites had yields below the suggested UK target of 15.3%, with an overall population yield of 14.6% (upper CI:15.4%).


V10Gy) were 11.9 Gy, 9.1 Gy, and 0.5% in IMRT. This could be lowered to 4.3 Gy, 2.5 Gy, and 0% in carbon ion planning and to 8.1 Gy, 6.1 Gy, and 0% in proton planning. Regarding the thoracic lesion no difference was found for the spinal cord. For the lumbar lesion maximum dose, D1 and percent volume receiving 5 Gy (V5Gy) were 13.4 Gy, 8.9 Gy, and 8.9% for IMRT; 1.8 Gy, 0.7 Gy, and 0% for carbon ions; and 0 Gy,<0.01 Gy, and 0% for protons. Estimated mean treatment times were shorter in particle techniques (6–7 min vs. 12–14 min with IMRT). This planning study indicates that carbon ion and proton RT can deliver high‐quality PTV coverage for complex treatment volumes that surround the spinal cord.Outcomes for selected patients with spinal metastases may be improved by dose escalation using stereotactic body radiotherapy (SBRT). As target geometry is complex, we compared SBRT plans using step‐and‐shoot intensity‐modulated radiotherapy (IMRT), carbon ion RT, and proton RT. We prepared plans treating cervical, thoracic, and lumbar metastases for three different techniques — IMRT, carbon ion, and proton plans — to deliver a median single 24 Gy fraction such that at least 90% of the planning target volume (PTV) received more than 18 Gy and were compared for PTV coverage, normal organ sparing, and estimated delivery time. PTV coverage did not show significant differences for the techniques, spinal cord dose sparing was lowered with the particle techniques. For the cervical lesion spinal cord maximum dose, dose of 1% (D1), and percent volume receiving 10 Gy (PACS number: 87.55.dk I.Spinal metastases are a common manifestation of malignant tumors, and progressive disease can result in pain, neurological disability, and reduced quality of life.Another important consideration for radiotherapy (RT) of the spine is the treatment time, as many patients experience substantial pain.One important toxic effect is SBRT‐induced vertebral compression fracture with a crude risk ranging from 11% to 39%, which can be clinically significant, resulting in mechanical instability and a need for surgical intervention.We describe a planning study comparing IMRT, carbon ion RT and proton RT plans in single dose of 24 Gy for spinal SBRT. For the sake of simplicity and comparison we considered only physical doses for carbon ion and proton RT and, therefore, give the respective dose unit Gy only.II.The planning CT scans of three patients previously treated for spinal metastases were included in a planning study to compare step‐and‐shoot IMRT, carbon ion scanned beam RT, and proton scanned beam RT. The techniques were planned using Oncentra MasterPlan by Nucletron  for IMRT, and TRiP98 for carbon ion and proton RT.Three cases were studied. Case 1 involved treatment to the cervical vertebral body . Case 2 involved a thoracic lesion. Case 3 was in the lumbar spine. Spinal bone metastases are frequently located partially within the vertebral body with pedicle involvement, therefore the PTV was defined according to this critical location next to the cord. The PTV was 8.4 cc for case‐group 1, 30.2 cc for case‐group 2, and 54.7 cc for case‐group 3. Computed tomography (CT) and magnetic resonance imaging were used to diagnose spinal metastases. In each case, the radiosurgical treatment plan was designed based on tumor geometry, proximity to spinal cord, and location. First priority was sparing the spinal cord; covering tumor to RT dose was secondary.The PTV was defined according consensus target volume definitions.CI=total volume receiving 24 Gy (cc)/volume of PTV (cc), as is consistent with ICRU 62.The prescription and planning objectives used for all techniques were the same. A single fraction of median 24 Gy was planned to the PTV such that at least 90% of the PTV received more than 18 Gy. Other objectives included a maximum PTV dose of 27 Gy, and a maximum point dose of 12 Gy to the spinal cord and 17 Gy to the partial cord PRV. OAR doses were aimed to be kept within suggested guidelines.A.V24Gy) were assessed. For the spinal cord PRV, the Dmax and the relative volume receiving at least 12 Gy (V12Gy) were assessed. Other OARs were evaluated according to the criteria described in the RTOG 0631 study.IMRT plans for all groups were generated for an Elekta Synergy  linear accelerator with an integrated multileaf collimator (MLC) system. The configuration of nine static beams with 6 MV was used for each group. For PTV Dmax, Dmean, D95%, and the relative volume of the PTV receiving at least 24 Gy  depending on the isoenergy layer, and step size in X and Y directions was 2 mm. The overlap in depth was 3 mm. The plans for proton beam were optimized with a spot size of 8–25 mm FHWM depending on the isoenergy layer. The step size in X and Y directions varied between 2 mm and 3 mm depending on the tumor size and site. Similarly, in depth the overlap varied between 2 mm and 3 mm.The dose optimization method was multiple‐field optimization . DVH evaluation was performed with Slicer3D.III.With all three delivery techniques  the planning objectives for spine SBRT could be met. Acceptable target coverage with more than 18 Gy at least 90% of the PTV and more than 23 Gy at mean dose, as well as dose along with the desired organ at risk sparing, were reached. Tables 1 to 3 display the dosimetric details of cervical, thoracic, and lumbar spine SBRT. Figures 1 and 2 show the corresponding dose distributions and DVHs.V10Gy were 11.9 Gy, 9.1 Gy, and 0.5%. This could be lowered to 4.3 Gy, 2.5 Gy, and 0% in carbon ion planning and to 8.1 Gy, 6.1 Gy, and 0% in proton planning. For the thoracic lesion no difference was found for the spinal cord. The D10Gy of the esophagus was 5.6 Gy for photons and 1.0 Gy for carbon ions and 0.1 Gy for protons. Lung dose was significantly higher with photons with a V5Gy of 8.9 Gy (right lung) and 6.3 Gy (left lung), but still well within tolerance.While dose to the PTV did not show significant differences for the techniques, dose to the spinal cord was considerably lower with the particle techniques. For the cervical lesion spinal cord maximum dose, D1 and V5Gy were 13.4 Gy, 8.9 Gy, and 8.9% for photons; 1.8 Gy, 0.7 Gy and 0% for carbon ions; and 0 Gy,<0.01 Gy, and 0% for protons. The conformity index favored particle techniques in all vertebral segments: cervical 0.85, 1.29, and 1.10; thoracic 0.91, 1.01, and 1.31; and lumbar 0.93, 0.96, and 0.95 . The calculated time of irradiation for the plans with particle techniques ranged 6–7 min, and for the plans with IMRT, 12–14 min per plan.For the lumbar, lesion dose to the small bowel was considerably higher than with ions. Maximum dose, D1 and IV.Bone metastases are a very frequent secondary diagnosis associated with an advanced tumor disease, with the vertebral column being the most frequent location.<1%) when the maximum spinal cord dose is limited to the equivalent of 13 Gy in a single fraction.Our planning study compared single‐fraction spinal SBRT plans performed with step‐and‐shoot IMRT, carbon ion RT, and proton RT for cervical, thoracic, and lumbar bone metastases. First of all, we showed the feasibility of SBRT plans for proton and carbon ion RT. In all localizations, dose to the PTV did not show significant differences for the techniques. A retrospective study of 18 Gy single‐fraction SRS showed a local control of 92% with a median follow‐up of seven months (1–50 months), and neither neurological complications nor radiological abnormalities were recorded.This planning study indicates that carbon ion and proton RT can deliver high‐quality PTV coverage for complex treatment volumes that surround the entire spinal cord. Large controlled trials are necessary to confirm these findings.


Tuberous sclerosis complex (TSC)-associated renal angiomyolipoma (AML) have a high lifetime risk of acute bleeding. MTOR-inhibitors are a promising novel treatment for TSC-AML, however adequate response to therapy can be difficult to assess. Early changes in MRI signal may serve as a novel early indicator for a satisfactory response to mTOR-inhibitor therapy of AML.Thirty-eight patients with the definite diagnosis of tuberous sclerosis receiving everolimus therapy and n = 19 patients without specific therapy were included. 1.5 Tesla MRI was performed including sequences with a selective fat suppression. Patients were investigated prior to the initiation of therapy (baseline) and after <3 months (n = 21 patients), 3 to 6 months (n = 32) and 18 to 24 months (n = 28). Signal and size changes of renal AMLs were assessed at all different timepoints. Signal-to-noise-ratio (SNR), contrast-to-noise-ratio (CNR) and size of angiomyolipomas were evaluated.Signal changes in 273 AMLs were evaluated. A significant and strong decrease of the CNR of AMLs following the initiation of therapy was measured in the fat-suppressed MR sequence at all time points, compared to the baseline: From 7.41±6.98 to 3.84±6.25 (p ≤ 0.05p = 0.002), 3.36±6.93 (p<0.0001), and 2.50±6.68 (p<0.0001) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively. Also, a significant, however less pronounced, reduction of angiomyolipoma size in the different groups was measured (from baseline 2022.2±2657.7 mm2 to 1854.4±1670.9 mm2 (p = 0.009), 1875.5±3190.1 mm2 (p<0.001), and 1365.8 ± 1628.8 mm2 (p<0.0001) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively). No significant changes in CNR (p>0.05) and size (p>0.05) were measured in the control group.mTOR inhibitor therapy in TSC patients results in an early and pronounced fatty transformation of AMLs on MRI. Fatty transformation could represent a novel early indicator of response to therapy in this patient collective. Tuberous sclerosis complex (TSC) is a rare autosomal dominant disorder that affects approximately 1.5 million people worldwide with a birth incidence of 1 in 6000 . The cliTSC is caused by decreased or absent expression of the genes TSC1 (hamartin) or TSC2 (tuberin) resulting in an aberrant mTOR-signaling and subsequent tumor growth . The mTOBeyond that, it has not been investigated how mTOR inhibitor therapy affects the different tissue types of angiomyolipoma, vascularization (angio-), myocytes (-myo-) and lipid cells (-lipoma), during the time-course of therapy.The aim of this study was to evaluate potential changes in the relative tissue composition of renal angiomyolipomas following the initiation of mTOR inhibitor therapy based on MRI measurements. Additionally, the time course of changes was evaluated.All patients were older than 18 years and definite diagnosis of TSC was established based on current diagnostic guidelines . We herePatients without a definite diagnosis of TSC were excluded from the analysis. MRI was not performed in patients with standard contraindications for MRI, including claustrophobia, specific metallic—items such as cochlear implants, central nervous system aneurysm clips, pacemakers/ defibrillators). Additionally, MRI data sets of the abdomen/kidneys had to be available prior to and following the initiation of the mTOR inhibitor therapy.Overall, a study population of 38 TSC patients with 273 angiomyolipomas and MR examination before initiation of everolimus treatment were included in this study. Of these, 21 patients  was imaged within three months of the initiation of the everolimus therapy, a group of 32 patients  was imaged within 3 to 6 months of initiation of the everolimus therapy, a group of 27 patients  was imaged within 18 to 24 months of initiation of the everolimus therapy. Antiepileptic co-medication was recorded and everolimus dosing as well as trough levels at time of MRI imaging were documented. Adverse events of grade 2 or higher according to MedDRA version 12.1 were recorded as well as everolimus treatment interruptions for longer than 2 weeks.Additionally, a control collective of 19 TSC patients  without mTOR inhibitor therapy and solely follow-up MR examinations was included. For details regarding the TSC patient population please see MRI imaging data sets were acquired between January 2010 and January 2017. MRI imaging was performed on a 1.5 T system  equipped with a standard abdomen matrix coil. First a T2 haste non-breathhold localizer scan was performed for anatomical orientation. Based on this scan the following sequences were planned: Transversal T1 spin echo and the following parameters: Field of view 320 mm, and matrix 256, slice thickness 5 mm, TR 550 ms, TE 8.4 ms, to averages, flip angle 90°. Transversal T2 haste: Field of view 320 mm, matrix 320 slice thickness 4 mm, TR 800 ms, TE 94 ms, averages 1, flip angle 180°. Coronal T2 haste: Field of view 400 mm, matrix 320, slice thickness 5 mm, TR 800 ms, TE 89 ms, averages 1. Transversal T1 flash (including in phase and opposed phase): On field of view 400 mm, matrix 320, slice thickness 4 mm, averages 1. Additional sequences included: Non-breathhold T2 haste scout to plan the following transversal free breathing navigator-gated T2 fatsat sequence (T2 FS) turbo spin echo (TSE) sequences, field of view 320 mm, matrix 320 slice thickness 4 mm, TR 3300 ms, TE 79 ms, 2 averages, flip angle 180°, frequency selective fat saturation.All images were analyzed using PACS workstations . Images were analysed independently, randomized and blinded to all clinical information.All imaging analysis was based on the navigator-gated T2 fatsat sequence (T2 FS) which was available in all patients. The main advantage of this sequence was, that it could be acquired in free breathing, compared to the other MR sequences of the MR imaging protocol which were breathhold sequences. Therefore, AMLs could be clearly delineated with a high spatial resolution. Breathing artifacts resulting from breath-hold artifacts were not present. This is especially relevant in patients with TSC-related developmental delays.In all patients, the largest three AMLs where evaluated and the area in mm2 was recorded. Measurements based on multiple regions of interests (ROIs) were performed on the imaging slice which demonstrated the largest angiomyolipoma area. Such an approach was chosen, as this represents a typical clinical approach for the assessment of the size of AMLs.AML), the signal of a reference muscle (SImuscle) and the noise . Noise (N) was determined in a ROI placed in the air ventral to the abdomen. The signal-to-noise-ratio (SNR) was measured between AMLs (SIAML) and noise : SNR = SignalAML / SignalN.Additionally, signal measurements of the angiomyolipomas were performed based on the same regions of interest as the size measurements. This included the assessment of the SNR  and CNR (contrast-to-noise-ratio) values of all angiomyolipomas. For the calculation of the SNR and CNR the following signal intensities were measured. The signal of the angiomyolipoma (SIAML) and muscle tissue (SImuscle). The CNR was calculated by the following formula:Contrast-to-noise-ratio (CNR) was measured between AMLs .All signal measurements were performed based on ROIs on the navigated T2 sequences in combination with a specific fat saturation pulse .At baseline, angiomyolipomas showed heterogenous signal properties on the T2 FS MR sequences. A mixture of areas with high and low signals on this sequence were present in all angiomyolipomas . VisuallThe baseline SNR and CNR values of angiomyolipomas in the control group were 15.8±6.44 and 8.94±6.07. The time period between baseline and follow-up scan was 9.50 ± 10.0 months in controls. These values did not differ (p > 0.05) from the baseline values of the therapy group.SNR and CNR were determined at different timepoints following the initiation of the mTOR therapy. Compared to baseline, a significant (p ≤ 0.05) reduction in SNR and CNR was measured already in the group with less than three months of mTOR inhibitor therapy. SNR values demonstrated a reduction from 15.2±7.95 to 11.1±6.85 (p<0.0001), 12.0±6.87 (p = 0.001), and 11.3±7.38 (p = 0.003) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively.Changes were more pronounced for the CNR measurements. A strong reduction of CNR values from 7.41±6.98 to 3.84±6.25 (p = 0.002), 3.36±6.93 (p<0.0001), and 2.50±6.68 (p<0.0001) was measured after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively .All size measurements were performed based on the same ROIs as the signal to noise ratio and contrast to noise ratio measurements.In the control group angiomyolipomas demonstrated an average size of 1105.7±1378.4 mm2.Compared to baseline, a significant reduction in angiomyolipoma size was already detected in the group with less than three months of mTOR inhibitor therapy. The size of angiomyolipomas was reduced from 2022.2±2657.7 mm2 to 1854.4±1670.9 mm2 (p = 0.009), 1875.5±3190.1 mm2 (p<0.001), and 1365.8 ± 1628.8 mm2 (p<0.0001) after less than 3 months, 3–6 months or 18–24 months of everolimus treatment, respectively. .Relative changes (%) of CNR measurements and changes in size of angiomyolipomas were directly compared. Changes in both parameters occurred simultaneously. Already after three months of mTOR inhibitor therapy, a relative reduction in CNR and area measurements was detected. The average reduction in CNR was however more pronounced (more than 60%) compared to the area measurements (more than 15%). Comparable relative changes in signal reduction were also measured in the 3 to 6 months group and the 18 to 24 months group. This indicates that main treatment effects of mTOR inhibitor therapy seem to occur in the first three months of therapy and only minor further changes occur at later time points. As expected, no significant changes in relative reduction of CNR and area measurements were detected in the control group of patients without mTOR inhibitor therapy.A relative reduction in CNR of ≥30% were seen in 66.7%; 74.3%, and 92.1% of treated patients after 3 months, 3–6 months, or 18–24 months, respectively. A relative reduction in CNR of ≥50% were seen in 52.1%; 44.1%, and 88.9% after 3 months, 3–6 months, or 18–24 months, respectively.Best percentage reduction of CNR and AML area reported at any time point under everolimus therapy is shown in Dosing and trough levels of everolimus are given in No AML bleeding events were documented during the study. Renal function was normal and remained stable in 32/38 (84.2%) of patients receiving everolimus. In 6/38 (15.8%) of treated patients renal function was already impaired at beginning of treatment and further declined from 1.63±0.63mg/dl at baseline to 2.53±1.01mg/dl serum creatinine after 36 months. AML signaling responses were independent of renal function.In all 19 control patients, renal function was normal and remained stable throughout the observation period.This study demonstrated that everolimus therapy in TSC patients results in an early and pronounced changes of tissue composition of angiomyolipomas on MRI. The appearance of AMLs in MRI was associated with a rapidly decreasing vascularization of angiomyolipomas and could represent a novel early indicator of response to mTOR inhibitor therapy in this patient collective.Following the onset of everolimus therapy, changes in tissue composition and size of angiomyolipomas occurred relatively early and simultaneously and were most pronounced in the first three months following the initiation of the therapy. No relevant further therapeutic effects were measured at later time points . After three months of therapy, the relative changes regarding the predominance of fatty tissue and the reduction of the vascular component were more pronounced compared to changes in size of angiomyolipomas. An early indicator of response to therapy, besides size, could be particularly important as the exact size of especially large and heterogenous angiomyolipomas can be difficult to assess.In our study we could detect a treatment response in MRI signaling in every patient receiving everolimus. This is in contrast to the randomized EXIST-2 study analyzing the volume reduction of AML under everolimus treatment where 15% of patients could either not be evaluated or did not show a treatment response . As a coDifferent studies demonstrated that the bleeding risk of angiomyolipomas is directly associated with the size of the angiomyolipoma. Therefore, a clinical cutoff of AMLs larger than 4 cm in diameter was defined for initiation of everolimus therapy ,10. For If an AML size reduction cannot be achieved or reliably measured after initiation of everolimus therapy the clinical consequence would be dose escalation of everolimus or even AML embolization. The former is associated with a higher rate of side effects, the later with a loss of functioning kidney tissue and potential loss of GFR. An early indicator for response to therapy could help reduce the percentage of uncertain assessments.On MRI, the different tissue types of angiomyolipomas, mature adipose tissue, dysmorphic blood vessels/microvessels and smooth muscle-like cells show different signal properties. Adipose tissue is hyperintense on T1 and T2 sequences, however hypointense if fat suppression is applied. Smooth muscle cells are T1 and T2 hypointense and do not show a signal loss on fat-suppressed sequences ,12. FluiFurther information regarding the tissue composition of AMLs can be derived, if gadolinium based contrast agents are administered. These contrast agents should however be avoided, especially in patients with impaired renal function, which is frequently observed in TSC patients.In the current study, a pronounced drop in contrast to noise ratio of AMLs was observed in the first three months following the initiation of the mTOR inhibitor therapy. This drop in signal reflected a fatty transformation in combination with a reduction of the vascular/microvascular component of angiomyolipomas. The reduction in the vascular component, which include small angiogenic vessels, could represent the initiating treatment effect of mTOR inhibitors which subsequently leads to a reduction in angiomyolipoma size The reduction in vascularization may be the main effect for effective bleeding prevention, and therefore may represent the true therapeutic effect. The current study is the first study to report such an early effect of mTOR therapy.This observation is in line with previous studies which demonstrated antiangiogenic properties of everolimus using blood-based biomarkers. mTOR is assumed to play a critical role in tumor vascularization, as it is part of the phosphatidylinositol 3-kinase/Akt/mTOR signalling pathway, which is implicated in tumor angiogenesis . PreviouLimitations of this study: Only adult patients were included in our study. No histopathological validation of changes of the tissue components of angiomyolipoma was performed.The precise assessment of size changes in angiomyolipomas can be challenging due to the heterogeneity of these complex lesions and spontaneous changes in angiomyolipomas morphology resulting from e.g. focal bleedings. Fatty transformation of renal angiomyolipoma on MRI could represent a novel early indicator to identify TSC patients which respond to mTOR therapy. Unnecessary dose escalation or even interventional therapy, such as embolization, could possibly be avoided in patients without clear size effect of mTOR therapy.


Bubalus bubalis) is considered an important source of high-quality milk and meat supply. The objective of this study was to investigate serotypes, virulence genes, and antibiotic resistance determinants profiles of Escherichia coli isolated from buffalo at some places in Egypt; noticibly, this issue was not discussed in the country yet.In Egypt as in many other countries, river water buffalo  analyzed for the presence of antibiotic resistance determinants and virulence genes.A number of 58 rectal samples were collected from diarrheic buffalo calves in different regions in Egypt, and bacteriological investigated for E. coli (24.1%); 6 were belonged to serogroup O78 (10.3%), followed by O125 , then O158  and one isolate O8 (1.7%), among them, there were 5 E. coli isolates showed a picture of hemolysis (35.7%). The isolates exhibited a high resistance to β lactams over 60%, followed by sulfa (50%) and aminoglucoside (42.8%) group, in the same time the isolates were sensitive to quinolone, trimethoprim-sulfamethoxazole, tetracycline (100%), and cephalosporine groups (71.4%). A multiplex PCR was applied to the 14 E. coli isolates revealed that all were carrying at least one gene, as 10 carried blaTEM (71.4%), 8 Sul1 (57.1%), and 6 aadB (42.8%), and 9 isolates could be considered multidrug resistant (MDR) by an incidence of 64.3%. A PCR survey was stratified for the most important E. coli virulence genes, and showed the presence of Shiga toxins in 9 isolates carried either one or the two Stx genes (64.3%), 5 isolates carried hylA gene (35.7%), and eae in 2 isolates only (14.3%), all isolates carried at least one virulence gene except two (85.7%).Overall 14 isolates typed as E. coli variants which have a public health importance.The obtained data displayed that in Egypt, buffalo as well as other ruminants could be a potential source of MDR pathogenic  Escherichia coli is a member of the genus Escherichia within the family Enterobacteriaceae. Members of this family are vastly extended in the environment. E. coli is ordinarily a non-pathogenic member of the animal intestinal flora. However, certain strains have developed virulence and antibiotic resistance factors, so may cause a variety of infections in humans and animals, strains of E. coli that cause enteric disease are stated enterovirulent or diarrheagenic E. coli (DEC) [li (DEC) .E. coli access into the human communities through the food chain [Ruminants represent a major reservoir for pathogenic od chain . Diagnosod chain .E. coli isolates with MDR phenotypes has been formerly reported and may extend from one ecosystem to another by lateral gene transfer; integrons [Presently, the rising of antimicrobial resistance is a public health concern, in particular the use and misuse of antimicrobials, especially in animal population as growth promoters. The main factor in the emergence of multidrug-resistance (MDR) strains is the ability of bacteria to gain and disseminate exogenous genes through mobile genetic elements . The upgntegrons .E. coli usually possess abundant virulence determinants that share in the disease pathogenesis; Shiga toxin-producing E. coli (STEC) represents a substantial emerging set of food-borne pathogens, as farm animals, particularly bovine, have been incriminated as natural reservoirs of STEC worldwide [E. coli are characterized by their ability to cause A/E lesions in the gut mucosa of human and animal hosts leading to diarrhea [The pathogenic orldwide . Attachidiarrhea .E. coli isolated from different animal and environmental sources in Egypt take a some attention [Recently, the studies concerned the virulence genes and serotypes of ttention -10, “butttention .”Escherichia coli, only a few reports on the role of buffalo as a reservoir of various E. coli pathotypes.In Egypt, like many developing countries, there are commonly used antibiotics in human as well as the farm animal population as aminoglycosides , β-lactam , and sulfa groups due to their low costs, so investigation of their resistance genes is of public concern. Although there were many researches over the world implicated ruminants, especially cattle, as a principal reservoir of enterovirulent As per CPCSEA guidelines, a study involving clinical samples does not require the approval of the Institute Animal Ethics Committee.Rectal samples were collected from 58 diarrheic buffalo calves in sterile swabs, dipped into trypticase soya broth were and incubated aerobically overnight at 37°C.Samples were streaked onto MacConkey sorbitol agar (oxoid); then, the lactose fermenting pink colonies were picked and cultured onto eosin methylene agar (oxoid) and incubated as described above. The green metallic colonies were picked and examined for their biochemical characters; API 20E kit (Bio Merieux) was performed according to manufacturer’s instruction to detect the biochemical profile of the isolated organisms.Phenotypical antibiotic susceptibility was tested applying the disk diffusion method on Mueller–Hinton agar plates (oxoid) according to the guidelines of Clinical and Laboratory Standards Institute . A panelet al. [The serological typing based on agglutination reactions of the somatic antigens (O). O antigens were identified as described by Guinée et al. . All avaE. coli isolates were propagated on blood agar base (oxoid) supplemented with 5% washed sheep erythrocytes. The plates were incubated at 37°C for 24 h, and the presence of a clear colorless zone surrounding the colonies indicated b-hemolytic activity [activity .DNA extraction from the samples was performed using the QIAamp DNA Mini kit  with modifications from the manufacturer’s recommendations. Briefly, 200 µl of the sample suspension was incubated with 10 µl of proteinase K and 200 µl of lysis buffer at 56°C for 10 min. After incubation, 200 µl of 100% ethanol was added to the lysate. The sample was then washed and centrifuged following the manufacturer’s recommendations. Nucleic acid was eluted with 100 µl of elution buffer provided in the kit.Primers used were supplied from Metabion (Germany) are listed in Tables-aadB, blaTEM, and Sul1) or diplex (Stx1 and Stx2) or (hylA and eae A) as described in the Tables-Primers were utilized in a 50-µl, PCR reaction containing 25 µl of EmeraldAmp Max PCR Master Mix , 1 µl of each primer of 20 pmol concentrations, 9 µl of water, and 10 µl of DNA template. The reactions were performed either multiplex  in ×1 Tris/Borate/ethylenediaminetetraacetic acid buffer at room temperature using gradients of 5 V/cm. For gel analysis, 30 µl of the products was loaded in each gel slot. A 100 bp ladder  was used to determine the fragment sizes. The gel was photographed by a gel documentation system  and the data were analyzed through computer software.E. coli strain ATCC35150 , and E. coli HB 101 inv+ were used as a positive control and S. aureus ATCC29737 as a negative control.Reference E. coli (24.1%); 6 were belonged to serogroup O78 (10.3%), followed by O125 , then O158  and one isolate O8 (1.7%), only 5 E. coli isolates showed a picture of hemolysis (35.7%). These results were some extent close to that obtained by Beraldo et al. [E. coli and STEC E. coli among buffalo and found that 76 out of 256 samples (29.7%) were positive, somewhat approach another study applied on fecal samples from 174 slaughter buffalo in Dhaka, Bangladesh, as 37.9% [et al. [E. coli in water buffaloes in Brazil “as the first survey in South America” ranged from 0 to 64%, depending on the farm. However, in another study in Italy, the incidence of isolation reached 70% (220/314) among Mediterranean water buffalo calves <4 weeks old affected by severe diarrhea with a lethal outcome [Of 58 collected rectal samples, there were 14 typed isolates as as 37.9% . On the  [et al.  reported outcome ; moreoveE. coli .1%; 6 weThe serotyping of the study isolates showed three serogroups O8, O125, and O158, which also detected among 36 different O groups in another study , the fouE. coli isolates were more frequently resistant to ampicillin (71.4%), amoxicillin (64.3%), followed by intermediate resistance to sulphaprim (50%) then gentamicin and kanamycin (42.8%), while the isolates were found to be highyly sensitive to ciprofloxacin, norfloxacin, trimethoprim-sulfamethoxazole, and tetracycline (100%), then less sensitive to amikacin and cephalosporine group (71.4%).The antibiotic sensitivity assay showed that the E. coli isolates were screened for presence certain antibiotic resistance determinant genes, the results obtained from E. coli serotypes which were used in mPCR, carried at least one gene, as 10 carried blaTEM (71.4%), 8 Sul1 (57.1%), and 6 aadB (42.8%), one carried the 3 genes (7.1%) and 8 carried 2 genes (57.1%). These results lead until there were 9 isolates could be considered MDR by an incidence of 64.3%. The previous investigations stated the isolated E. coli strains were resistant most frequent to erythromycin (95.83%), cephalothin (62.5%), amikacin (54.17%), kanamycin (45.83%), and gentamicin (41.67%) [E. coli strains were susceptible to all antimicrobials tested. Resistance to one drug  and resistance to two antimicrobials  were found in 10 (17.8%) and 2 (3.6%) of the strains, respectively [The 14 (41.67%) . While iectively .Stx genes which constitute two major subfamilies; Stx1 and Stx2 [E. coli pathogenicity; as intimin coded by eae gene, which responsible for the attachment and invasion of the organism to mucosa, and hylA gene which expresses the hemolytic activity [Shiga toxins play a major role in intense inflammatory response and may explain the ability of STEC strains to cause severe illness in affected human and animals. These toxins were expressed by and Stx2 . Besidesactivity .Stx1 gene in 6 isolates (42.8%), two were belonged to both serotypes O125 and O78, while O8 and O158 represented one for each, while Stx2 was present in 4 isolates (28.6%), belonged to both O125 and O78. One O125 isolate harbored the two genes, overall, 9 isolates carried either one or the two Stx genes (64.3%).The results obtained from hylA gene in 5 isolates (35.7%), the same of what presented in eae was present in 2 isolates only (14.3%), belonged to both O8 and O78. One O8 isolate harbored the two genes. These results were near that obtained Oliveira et al. [stx2, 43 (39.5%) carried stx1 and stx2 sequences, and only 24 (22%) harbored the stx1 sequence and no intimin. Furthermore, the prevalence of virulence genes in 49 non-O157 E. coli strains, 41 showed detection of stx1 (83.1%), 4 stx2 (8.2%), 4 both (8.2%), 3 showed detection of hylA (6.1%), and no intimin was detected, Beraldo et al. [et al. [stx1, stx2 in 28.8% and eae was found in 14.4% in tested isolates. While in Vu-Khac and Cornick [stx-positive strains were recovered from 27% of buffaloes and eae gene was not detected in buffalo isolates.On the other hand, the results obtained from a et al.  who stat of hylA .1%, and  [et al.  characteE. coli” that harboring any gene for Shiga toxins (stx1 or stx2) was detected in 24 (6.61%) of the 363 E. coli isolates [et al. [E. coli isolates for the presence of the virulence factors Stx1, Stx2, haemolysins, eae, and found that Stx1 (80%) more frequent than Stx2 (27%) while the eae and hylA were positive in all isolates.Moreover, “isolates . On the  [et al.  characteE. coli and may constitute a prospective human threatening as a source of certain zenotic serotypes infection through milk and meat consumption. The problem is more exacerbating with the marked incidence of multi-antimicrobial resistance isolates, so the attention should be directed to hygienic precautions, as well as careful use of antibiotics in farm animal husbandry.The obtained data of our study revealed that the Egyptian buffalo may play role in colonization and dissemination of pathogenic, diarrhegenic ASH supervised the experiment. STO and ASH shared in the isolation and the antibiotic susceptibility performance, EAF collected the samples and help in antibiotic susceptibility, ASH and EAF identified the isolates by API 20E kit. STO, SMS, and ASH performed PCR, ASH prepared and reviewed the manuscript. All authors read and approved the final manuscript.


Chronic obstructive pulmonary disease (COPD) is characterized by chronic incompletely reversible poor airflow and air trapping and usually this debilitating disorder limits the outside activities of the patients depriving them of sunlight which is a rich source of Vitamin D. The objective of this study was to determine the effect of vitamin D supplementation in reducing number of acute exacerbation in COPD patients.This randomized control trial was conducted at East Medical Ward Mayo Hospital Lahore from January to December 2015 as exacerbations of COPD are season dependent. Diagnosis was confirmed by performing Pulmonary Function Tests (PFTs). Basic demographical information was obtained and baseline PFTs of the patient was done. Only Group A patients was treated with oral vitamin D intake of 2000 IU daily for 6 months. Vitamin D level was measured at 0, 2, 4, and 6 months and exacerbation of COPD, FEV1 and FVC was measured weekly. Both the groups were given standard treatment for exacerbation of COPD. Spirometry was repeated at each visit. Blood samples were collected every 2 months for vitamin D. Supplementation was stopped if vitamin D level exceeded 100ng/ml.The mean age of the patients was 46.28±8.83 years, the male to female ratio was 1.8:1. The mean 25(OH) level at baseline was 24.08±2.58 and at 6th month was 29.60±8.74. The mean FVC at baseline was 77.83±5.49 and at 6th month was 91.34±5.52. The exacerbation at baseline was present in all 120(100%) patients and at 6th month was reduced to 4(3.3%).Vitamin D supplementation has significant effect in reducing number of acute exacerbation in COPD patients when it is given for prolonged period. The main reason for Vitamin D deficiency is lack of ultraviolet-B radiation from less sun contact, and this result in lack of vitamin D production in skin. About 3% of the human genome regulates by vitamin D endocrine system.3Hypovitaminosis D is related with COPD according to Quint JK and in the general population increased susceptibility to infection.5Few studies have measured the significance of vitamin D deficiency in COPD by calculating serum levels of 25-hydroxyvitamin D (25-[OH]D), which is the important circulating vitamin D metabolite and recognized as the finest short-term biomarker of entire contact to vitamin D. With disease development, marked by decay in FEV1, patients grow systemic significances and became prone to infectious exacerbations which are precipitated by concomitants vitamin D deficiency.6Deficiency in 25-hydroxyvitamin D is related with emerging risk of infections containing influenza, TB and pneumonia.8Of note, low serum 25-hydroxyvitamin D (25-[OH]D) levels, reproducing vitamin D status, are related with reduced FEV1, and it is present in 60% to 75% of severe COPD patients.2According to the Vitamin D Council, vitamin D levels above 30 - 40 ng/mL may reduce the risk of COPD. To reach these levels, most people need to take 1000–5000 international units (25–125 mcg) per day of vitamin D3, an active form of vitamin D that is produced under the skin. However, they also stress that, because there is considerable variation from person to person, proper dosage should be determined by measuring a patient’s vitamin D blood levels before, and several months after, taking vitamin D3 additions or increasing ultraviolet-B exposure.9An attractive target for intervention studies are particularly for COPD, the vitamin D pathway is due to lack of vitamin that can increase chronic airway and systemic inflammation, decrease bacterial clearance, and urge the chance for infectious exacerbations at the same time.Data was collected after approval of synopsis from ethical committee. After taking informed consent, all patients were enrolled in this study from medical units of Mayo Hospital Lahore. Basic demographical information  was obtained and baseline pulmonary function test (PFTs) of the patient was done.-2, FEV1 less than 80% of predicted & forced expiratory volume in first second FEV1/ forced vital capacity (FVC) < .7 and patients with vitamin D levels below 30 ng/ml.Patients having age between 18-60Y of either gender, Patients with normal BMI i.e. BMI = 19-24.5 kgmPatients with a history of asthma, bronchiectasis, carcinoma of the bronchus, or other significant respiratory disease. Patients having Serum calcium >10.5 mg/dL. Those with history of diseases like nephrolithiasis, hypercalciuria, malignancy, tuberculosis, sarcoidosis, Paget’s disease, malabsorption syndromes. Hepatic or renal insufficiency (creatinine >1.5 mg/dl and estimated creatinine clearance <20 ml/minute), Use of active metabolites of vitamin D within 6 months of screening and female patients on contraceptives.Patients were divided randomly in two groups A and B. Group A patients received oral vitamin D 2000 IU daily for 6 months. Vitamin D level was measured at 0, 2, 4, and 6 months and exacerbation of COPD, FEV1 and FVC was measured weekly. Acute exacerbation of COPD was defined as “A decline in the base line FEV1 by 10 % or more for a particular patientTime to first exacerbation was assessed by quantifying the days between randomization and the first exacerbation. Both the groups were given standard treatment for exacerbation of COPD. To obtain data on exacerbations, researchers asked the participants to complete diaries weekly with FEV1, FVC, detailed respiratory tract symptoms, visits to health care providers, hospitalizations, and changes in medication. At each visit, diaries were reviewed in the participant’s presence. Spirometry was repeated at each visit by using standard equipment. Blood samples were collected every 2 months to measure serum vitamin D levels. Vitamin D supplementation was stopped in patient whose serum vitamin D level exceeded 100ng/ml (optimum level). All the data was collected by the researcher himself on a prescribed proforma.All data was entered and analyzed using SPSS version 20. Qualitative data was presented in form of frequency (%). Quantitative data was presented in form of Mean ± S.D. P-value < 0.05 was considered as significant.In this study total 120 cases were enrolled. The mean age of the patients was 46.28±8.83 years with minimum and maximum ages of 30 & 60 years respectively. In our study 78(65%) patients were male and 42(35%) patients were females. The male to female ratio of the patients was 1.8:1. In our study the 97(80.8%) patients were smokers and 23(19.2%) patients were non-smoker and the mean BMI of the patients was 22.57±1.72 kg/m2. The study results showed the mean 25(OH) level which is depicted in The study determined the effect of vitamin D supplementation in reducing number of acute exacerbation in” COPD” patients. Vitamin D deficiency is prevalent amongst patients with chronic obstructive pulmonary disease (COPD) and comes to be more frequent with increased disease severity. Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease, characterized by persistent air flow limitation that is usually progressive and associated with an enhanced chronic inflammatory response of airways and the lungs to noxious particles or gases; exacerbation and comorbidities contribute to the overall severity in individual patients.11In our study the mean 25(OH) level at baseline was 24.08±2.58 and at 6th month was 29.60±8.74. The mean FEV1 at baseline was 67.54±5.50 and at 6th month was 78.97±6.94. The mean FVC at baseline was 77.83±5.49 and at 6th month was 91.34±5.52. The exacerbation at baseline was present in all 120(100%) patients and at 6th month it was present in 4(3.3%) patients. Statistically insignificant difference was found between the dyspnea, sputum volume, sputum purulence, cough, fever, common cold, wheezing, sore throat but for exacerbation, the difference was significant. Quint JK reported that 25-hydroxyvitamin D deficiency is associated with COPD and increased susceptibility to infection in the general population.12According to a recent meta-analysis, the benefits of supplementation were only present when baseline 25-OHD levels are very low <10 ng/ml). ng/ml.10Vitamin D can be beneficial in reducing exacerbations but it exerts this effect when it is taken in adequate amount and moreover for a prolonged period of time. Moreover, not every symptom benefitted with vitamin D replacement. So, further studies should be encouraged with different methodology and design to prove benefits of vitamin D in COPD.DMK conceived and designed the manuscript.AU and NFB did data collection and manuscript writing.FAR and SI did statistical analysis & editing of manuscript.KW did review and final approval of manuscript.


The current treatment for posterior capsular opacification (PCO), neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy, may lead to increased intraocular pressure (IOP). Our aim was to survey routines in the management of IOP spikes and to identify the rate of IOP spikes following prophylactic apraclonidine treatment. A survey questionnaire among ophthalmologists and a retrospective registry review was used. Patients were administered apraclonidine 0.5% prior to capsulotomy. The IOP was measured before and 1 hour postprocedure. A total of 71% of responders (n = 45) routinely prescribe topical IOP-lowering medication and 82% routinely measure IOP before or after capsulotomy. The registry analysis included 87 eyes of 75 patients. Mean IOP decreased by 0.9 ± 3.3 mm Hg  following capsulotomy. No patient reached IOP values above 21 mm Hg following the procedure, with 3.4 and 1.1% of patients demonstrating an IOP elevation of more than 3 and 5 mm Hg respectively. No association was found between number of laser shots, mean laser power, or comorbid conditions, such as diabetes, hypertension, or glaucoma status with posttreatment IOP. Most ophthalmologists surveyed routinely prescribe prophylactic IOP-lowering medication and measure IOP before or after capsulotomy. Mean IOP remained clinically stable following capsulotomy with prophylactic apraclonidine instillation, and no patient reached IOP values above 21 mm Hg. Differences in laser delivery or comorbid conditions were not associated with posttreatment IOP. Considering that no patient demonstrated a clinically significant IOP spike following prophylactic apraclonidine instillation, perhaps routine measurement of IOP following primary Nd:YAG laser may be reserved for high-risk patients only. In this work, we showed the prophylactic effect of apraclonidine 0.5% and suggest that measuring IOP after the procedure is necessary only in certain high-risk cases, possibly helping to reduce workload and patient waiting time and improving quality of service. Achiron A. Intraocular Pressure Spikes following Neodymium-doped Yttrium Aluminum Garnet Laser Capsulotomy: Current Prevalence and Management in Israel. J Curr Glaucoma Pract 2017;11(2):63-66. Although considered safe, it may result in retinal detachment, lens subluxation, and lens pitting. The most common complication is a transient increase in IOP, which may occur in 15 to 36% of patients who receive no prophylactic treatment.6 This IOP spike may lead to additional injury in eyes with advanced glaucomatous optic nerve damage.2Posterior capsular opacification is the most common postoperative complication of cataract surgery with a cumulative 5-year incidence of H.9%.12 Routine practice and outcomes in real-life settings, however, have not been as thoroughly explored. Apraclonidine 0.5% is a common choice as a prophylactic treatment prior to laser capsulotomy.813 Reported rates of IOP spikes above 5 mm Hg following prophylactic apraclonidine 0.5% and capsulotomy vary between 2 and 8.5%.251112Several controlled studies from recent decades have investigated IOP-lowering agents and demonstrated successful control of IOP.The purpose of this study was to survey routines in the management of post Nd:YAG laser capsulotomy IOP spike in Israel and to identify the rate of postprimary NdYAG laser capsulotomy IOP spikes following one drop of prophylactic apraclonidine 0.5% treatment.https://goo.gl/forms/87ZCQMO0l89sFqow2).Questionnaires were sent via e-mail to ophthalmologists registered at the Tel Aviv University Continuous Medical Education (CME) network. Ophthalmologists were asked to complete a 14-question internet-based survey regarding their IOP management routine, following cap-sulotomy  and visual acuity was conducted in addition to three logistic regression analyses. Successful outcomes following treatment were defined as those having an IOP < 21 mm Hg, absolute change in IOP ≤3 and ≤5 mm Hg, and IOP change <20%. This study was approved by the Edith Wolfson Institutional Review Board Committee.Total response rate for the survey questionnaire was 54% (45 of 83), responses were received from two-thirds of all certified ophthalmology teaching departments in Israel (13/19). The mean age of responders was 36.6 ± 8.4 years, 65.9% were male, 75.0% were residents, and the median of experience in ophthalmology practice was 3.0 years. The IOP measurement was routinely performed before and/or after the procedure by 81.8% of responders ; 18.2% do not measure IOP at all and 54.5% responded that they measured IOP twice (before and after capsulotomy).Topical medication to lower IOP before and/or after the capsulotomy was prescribed by 74.4% of responders ; 25.6% do not initiate any prophylactic IOP reduction treatment and 16.3% responded that they routinely prescribe topical medication twice (before and after capsulotomy).Of responders who routinely prescribe topical IOP-lowering medication, 81.8% also measure, at least once, the IOP (54.5% before and 59.1% after capsulotomy). Only 54.5% of responders who do not prescribe any topical antiglaucoma therapy also measure IOP at least once. Average time from preventive IOP treatment to capsu-lotomy was 15.9 ± 14.6 minutes (median 7.5 minutes).A total of 87 eyes of 75 patients  were included in the study. One eye of one patient was excluded because the patient had undergone previous Nd:YAG laser capsulotomy in that eye. The mean age was 75.6 ± 9.3 years; 29.9% had diabetes, 64.4% had systemic hypertension, and 14.9% had glaucoma . Mean time from cataract surgery was 32.0 ± 22.4 months. The mean number of laser shots was 21.8 ± 12.2 and mean laser power was 3.1 ± 0.5 mJ.Following capsulotomy and apraclonidine prophylactic treatment, average IOP remained clinically stable . Three cases (3.4%) experienced an increase in IOP of more than 3 mm Hg and only one case (1.1%) more than 5 mm Hg.vs 13.6 ± 2.2 mm Hg respectively, p = 0.01). There was no significant posttreatment difference in the mean IOP . The absolute change in IOP, however, was larger in the glaucoma patients group . None of the eyes demonstrated a clinically significant rise in IOP  to either posttreatment IOP or IOP change.279 When prophylactic treatment is prescribed, however, an IOP spike above 5 mm Hg is seen in only 2 to 8.5% of cases.2 The increased IOP may be caused by reduced aqueous humor outflow facility due to capsular debris, cells , fibrin, pigment, and other materials that may clog the trabecular meshwork. Shock waves created by the laser may also damage the trabecular meshwork, causing clogs.Acute IOP elevation following capsulotomy is common among patients who do not receive prophylactic treatment and may occur in 15 to 36% of cases.8 reported that 1% of 101 patients had IOP spikes over 5 mm Hg following their capsulotomies. Barnes et al2 reported a 2% rate among 47 patients treated with either acetazolamide or apracloni-dine. Unal et al11 examined 115 patients and reported a stable IOP following apraclonidine and capsulotomy (from 16.1 to 15 mm Hg) and a relatively high rate of IOP spikes > 5 mm Hg seen in 8.6% (5/58) of their patients.In our study, patients received prophylactic apra-clonidine and 1.1% of cases (1 of 87) experienced an IOP increase above five, with no patients reaching IOP values above 21 mm Hg. These results are in line with those of other researchers when using prophylactic IOP-lowering medication. Holweger and Marefat2 also reached a similar conclusion, showing that only 4% (1/23) of glaucoma patients who received apraclonidine prior to their capsu-lotomies experienced an IOP rise greater than 5 mm Hg.Apraclonidine 0.5% was effective in our glaucoma subgroup, with a mean IOP reduction of 2.6 ± 4.0 mm Hg . Moreover, glaucoma status was not a contributor for the risk of an IOP spike in our cohort. Barnes et al14 who demonstrated that higher laser power is associated with a greater IOP spike.We did not find any of the investigated laser parameters to have a significant clinical effect on IOP change or posttreatment values. This is in contrast to a report by Ari et al,15 It is therefore important to critically assess every decision affecting patient waiting times in the clinic. Given the low rates of IOP spikes in patients treated with IOP-lowering medication, reported here and in other studies, it might be reasonable to consider this avenue of action in low-risk patients.One possible implication arising from these results is the possibility to forego the 1 hour postlaser IOP measurement. Long waiting times are a major source of patient dissatisfaction and may adversely affect clinical outcomes and patient compliance with treatment regimens; waiting times have been found to be an important factor in rating service quality and overall patient satisfaction.Our survey included responses on the management of IOP spike following capsulotomy from two-thirds of all certified teaching departments in Israel (13/19). By targeting the university CME network contacts list, we had achieved high response rate from residents. As residents perform capsulotomy from an early stage in their residency, the survey results encompassed current practice and were exposed to limited recall biases.To conclude, most ophthalmologists surveyed routinely prescribe prophylactic IOP-lowering medication and measure IOP before or after capsulotomy. Mean IOP remained clinically stable following capsulotomy with prophylactic apraclonidine instillation. Increase in IOP above 5 mm Hg was observed in 1.1% of cases (1/87) and no patients reached IOP values above 21 mm Hg following the procedure. Differences in laser delivery or comorbid conditions were not associated with posttreatment IOP.In this work, we showed the prophylactic effect of apra-clonidine 0.5% and suggest that measuring IOP after the procedure is necessary only in certain high-risk cases, possibly helping to reduce workload and patient waiting time and improving quality of service.


A correct diagnosis and optimal treatment planning is essential for success in implant dentistry. Proper diagnosis of bone quality is an important part of the diagnostic procedure.The purpose of this study was to correlate the tactile sense of the surgeon in the assessment of bone density to the histomorphometric analysis of bone quality.In this study, 56 bone samples from 33 patients were harvested from implant sites with trephine drills. The samples were analyzed with Image J software. In the samples following parameters were measured: BV/TV, superficial cortical plate thickness, the number and thickness of haversian canals in cortical bone and the number, thickness and distance of trabecules in cancellous bone. The clinical hardness of bone during drilling was evaluated by surgeon according to Misch. GEE analysis with exchangeable correlation structure and linear model was used to evaluate the relationship between the tactile sense of the surgeon and histomorphometric parameters and all analysis was adjusted for two confounding variables: gender and location.P-value=0.05), and shown marginally significant correlation with mean superficial cortical bone thickness  and number of haversian canals  in cortical bone.There were 51.79% implants in D2 samples and 48.21% in D3. Bone classification according to Misch was significantly correlated to distance of trabecules in cancellous bone (There were differences between our results and others. The authors believed that these differences mainly are because of confounding factors, that in this study were eliminated. The clinical finding during surgery can approximately explain the histologic properties of bone.It is concluded that tactile sense of the surgeon can exhibit the histologic properties of the bone, and we are able to estimate the healing prognosis of the bone in implant placement. Boneery time . Among tery time .The first and most accepted classification of bone quality introduced with Lekholm & Zarb in 1985 , 29. ThiBone quality type I: Almost all areas of the jaws consist of homogeneous and compact bone; Bone quality type II: A thick layer of compact bone surrounding a central area of dense trabecular bone; Bone quality type III: A thin layer of cortical bone around a central area of dense trabecular bone; and Bone quality type IV: A thin layer of cortical bone surrounds a central area of low-density trabecular bone , 29. An There are several methods for assessment of bone quality, but the documents are rare about the reliability; more studies comparing the gold standard with other methods are required . The besThe aim of this study was to evaluate the relationship between subjective method of bone density determination; “tactile sense of the surgeon” and the histomorphometric analysis of an implant recipient site biopsies.21). Written informed consent was obtained from all the selected patients.The samples consisted of 56 bone samples from 33 patients treated with Dyna Dental Engineering BV  in a private dental office. Eligible samples were selected based on inclusion and exclusion criteria after clinical and radiographic assessments (Table 1) This drill had smaller diameter of the final drill to ensure the correct primary stability. Drilling was made with 8 mm depth and a new drill was used for each patient to have a perfect drilling ability in all patients. Drilling was performed under profuse irrigation at 800 r.p.m. The selection of implant site was randomized. The bone scoring was recorded during site preparation based on Misch (1993). The biopsies were analyzed histomorphometrically in a blind fashion.At the time of surgery after anesthesia a full thickness flap was elevated. For precise drilling a surgical stent was made for each patient. A trephine drill with 2.3 mm inner diameter, 3.0 mm outer diameter and 10 mm height were used as a first drill for implant site preparation. 3- Bone volume density/ Trabecular bone volume (%): It is defined as the coefficient of trabecular bone to tissue volume (Pereira 4- Trabecular thickness (µm): Average of trabecular thickness from min and max5- Trabecular Number in each mm2)6- Trabecular distance (µm): Average of trabecular distance  samples had D2 bone quality and 27 (48.21%) samples had D3. This selection was because of D1 and D4 bone qualities are easy to recognize by tactile sense of the surgeon and the difficulties in practice is for determination between D2 and D3 bone types .P-value =0.13) Mean thickness of superficial cortical plate in D2 was 1481.80 µm(SE= 152.68) and in D3 was 1138.51 µm (SE=120.14). The difference was 343.29 µm (SE=189.17) and this difference was marginally significant.  Mean Number of haversian canals in D2 was 23.88 (SE=4.81) and in D3 was 14.67 (SE=3.71). The difference was 9.21 (SE=3.32) and this difference was statistically significant. Mean BV/TV in D2 was 0.59% (SE= 0.04) and in D3 was 0.49% (SE=0.05). The difference was 0.10% (SE=0.06) and this difference was not statistically significant.  Mean trabecular thickness of cancellous bone in D2 was 171.33 µm(SE=10.19) and in D3 was 162.61 µm (SE=12.56). The difference was 8.72 µm (SE=11.95) and this difference was not significant.  The Mean trabecular number of cancellous bone in D2 was 20.00 (SE=1.03) and in D3 was 19.33 (SE=1.48). The difference was 0.68 (SE=1.53) and this difference was not significant.  Mean trabecular distance of cancellous bone in D2 was 142.87 µm(SE=15.91) and in D3 was 190.70 µm (SE=21.06). The difference was 48.83 µm (SE=24.80) and this difference was marginally significant.  (Table 2).Mean thickness of haversian channels in D2 was 167.17 µm(SE=21.69) and in D3 was 268.62 µm (SE=58.57). The difference was 101.45 µm (SE=69.97) and this difference was not significant. . In other studies the authors didn’t explain any adjustment of these factors, that it can be the main reason for existing differences. In this study, we have shown that as we expect, the denser bone in histomorphometric evaluation is harder on the tactile sense of the surgeon. Indeed, the only parameters that have shown significant correlations with tactile sense of the surgeon was: superficial cortical thickness, haversian canal number of cortical bone and the distance between trabecules of cancellous bone.Therefore, it can be understood that the tactile sense of the surgeon can exhibit the histologic properties of the bone, and we are able to estimate the healing prognosis of the bone in implant placement. Thus, according to our results we can not exactly explain on the basis of tactile sense that which parameter in histologic evaluation is affecting the results.Bone quality according to Misch can approximately exhibit the histologic properties of the bone. We can trust on our tactile sense during surgery for estimating the healing process and suitable time for implant loading.


Ovarian cancer is the most lethal cancer involving the female pelvic reproductive system. Its incidence increases with age and with an aging population, its prevalence should also increase. The goal of our retrospective study is to report our experience in treating women over 65 years of age, with a diagnosis of primary ovarian cancer, using standard intravenous chemotherapy.The medical records of 78 patients>65 years of age diagnosed with primary ovarian cancer at the Yale Cancer Center between 1996–2006 were retrospectively reviewed and included in our analysis. Patients had stage I–IV disease .2 and carboplatin AUC 5. The hazard ratio for PFS and OS for patients who had dose reduction/discontinuation versus those who completed the prescribed dose was 1.3 (95% CI 0.51–3.26) and 0.63 (95% CI 0.17–2.33), respectively.Sixty-three of 78 women (80.8%) completed the prescribed regimen; and 62 women did not require a dose reduction or chemotherapy discontinuation. The most common reason for a dose reduction or treatment discontinuation was fatigue (6.4%), neutropenia (2.6%), patient preference (2.6%), and multiple co-morbidities (2.6%). The most commonly used regimen was paclitaxel 175mg/mOur findings illustrate that elderly women are able to tolerate standard chemotherapy with relatively few significant adverse effects. While different treatment modalities in ovarian cancer are continually being evaluated, additional prospective studies are required to better understand the tolerability and efficacy of such treatment in the elderly population. It is the leading cause of death in cancers involving the female pelvic reproductive system in the United States [Cancer is one of the leading causes of morbidity and mortality worldwide, with the number of new cases expected to increase over the next 2 decades . Ovariand States . With and States . To dateThe medical records of 78 patients 65 years of age or older diagnosed with primary ovarian cancer at the Yale Comprehensive Cancer Center between 1996–2006 were retrospectively reviewed and included in our analysis. Women younger than 65 years of age were excluded. Patients were identified through the Tumor Board Registry of Yale-New Haven Hospital. Patients had stage I–IV disease . The diagnosis of a primary ovarian cancer was confirmed by pathology review of biopsy and surgical specimens at our institution. In addition to stage, other demographics and clinical data included grade, histology, chemotherapy dose, number of cycles received, dose reductions, and development of treatment related toxicities. Histological subtypes were collected for 40 of the 78 ovarian cancer cases, and 37 (92.5%) of these cases were of epithelial type. Patients received standard systemic therapy for primary ovarian cancer consisting of carboplatin and paclitaxel. Six out of 78 patients treated earlier in this series also received cyclophosphamide in addition to carboplatin and paclitaxel. The study cohort was retrospectively analyzed and progression-free survival (PFS) was calculated as time from the initial diagnosis to the date of disease recurrence, progression, or last contact. Overall survival (OS) was calculated as time from initial diagnosis to the date of death or date of last documented contact for living patients.All patients were evaluated and treated by a gynecologist oncologist. We reviewed patient records and collected the following information: clinical examination, pathology results, diagnostic imaging findings, laboratory results, and treatment plan. Ovarian cancer staging was determined using the 1988 International Federation of Gynecologists and Obstetricians (FIGO) staging system and was evaluated by a combination of histological data and diagnostic imaging. Staging data was available for all but 4 cases.2 administered every 3 weeks. Six out of 78 patients also received 600 mg/m2 of cyclophosphamide therapy in addition to carboplatin and paclitaxel. Sixty-five out of 78 patients (83.3%) received neoadjuvant chemotherapy. We found that 53 of 78 patients completed 6 cycles or greater of a regimen consisting of at least 175 mg/m2 paclitaxel and an AUC ≥ 5 for carboplatin.Patients received intravenous carboplatin at an Area Under the Curve (AUC) dose ranging from 2 to 7.5 and intravenous paclitaxel dose ranging from 40 to 225 mg/mWe used Cox regression analysis to estimate the hazard ratios associated with relapse and death risks for different disease stages. Kaplan-Meier analysis provided estimates of the survivor functions for the different disease stage groups. Significance was based on the log-rank test. We used the statistical system R (version 3.2.0) for all computations.The median age of patients was 76 years (range 65–93). Five patients (6.4%) had stage I disease, 8 patients had stage II (10.3%), 36 patients had stage III (46.2%), and 25 patients had stage IV (32.1%) disease. Four patients (5%) did not have staging data available. The most commonly recorded treatment related toxicity was fatigue (34.6%), followed by nausea (16.7%) and neuropathy (15.4%). Nineteen out of 78 patients (24.4%) did not have any treatment related toxicity recorded . The mos2 of paclitaxel and AUC 5 Carboplatin  and 0.63 (95% CI 0.17–2.33), respectively. Stage IV was associated with significantly greater risk for progression or death, with hazard ratios for PFS and OS between Stage IV versus Stage I/II disease of 3.65 (95% CI 1.37–9.69) and 6.24 (95% CI 1.29–30.2), respectively.However, women with Stage III disease had similar prognosis with those with Stage I/II disease (hazard ratio for PFS and OS between Stage III versus Stage I/II disease was 1.44 (95% CI 0.59–3.52) and 2.01 (95% CI 0.42–9.56), respectively)  and 5.The median PFS for Stage I/II, III, and IV disease was 5.06, 1.83, and 1.12 years, respectively .The median OS for stage IV disease was 3.51 years and 8.57 years for stage III disease. The median OS was not reached for stage I/II .Retrospective studies have shown that elderly patients with ovarian cancer received reduced chemotherapy doses compared to their younger counterparts as a result of their age. A large population based study evaluating the influence of age on treatment of ovarian cancer found that only 45% of patients aged 70 or older underwent optimal treatment compared to 83% of patients aged younger than 70, even in the absence of co-morbidity . GiulianThe majority of patient’s in our study had stage III or IV disease at the time of diagnosis, which is consistent with the findings from the SEER database on ovarian cancer. In the US, only 14.7% of women with ovarian cancer are diagnosed at the local stage (stage I disease) . This ma2), which is considered a standard treatment for ovarian cancer [2) once every 3 weeks for 6 cycles. Results showed that 68.1% of these women were able to complete the above regimen without having dose reduction or stoppage during the mandated 6 cycles [The most commonly used regimen in our study was carboplatin (AUC 5) with paclitaxel , versus elderly patients who received sub-optimal therapy. Results of the study showed an improved prognosis regarding PFS (18 vs. 11 months) and OS 31 vs. 20 months) when compared to those who received sub-optimal oncologic treatment . Similar months wOur retrospective analysis adds to the mounting evidence that elderly women are able to tolerate standard chemotherapy with relatively few significant adverse effects. With the aging population, we can expect to see increasing cases of ovarian cancer worldwide. While different treatment modalities in ovarian cancer are continually being evaluated, additional prospective studies are required to better understand the tolerability and efficacy of such treatment in the elderly population.


Super-resolution imaging of synaptic and Extra-synaptic AMPA receptors with different-sized fluorescent probes. Published 27, July 2017There was an error in the histogram of Figure 4–figure supplement 3b, which showed identical histograms at 0.2% and 1.0% biotin conditions. We accidently put the histogram of 0.2% biotin in place of the 1.0% biotin condition. We have now corrected this. Correcting this error does not affect any of the quantitative data reported in the text or the conclusions of the study.The article has been corrected accordingly.The corrected Figure 4–figure supplement 3 is shown here:The originally published Figure 4– figure supplement 3 is shown here:


The long-term downward national U.S. trend in heart disease-related mortality slowed substantially during 2011–2014 before turning upward in 2015. Examining mortality trends in the major subgroups of heart disease may provide insight into potentially more targeted and effective prevention and treatment approaches to promote favorable trajectories. We examined national trends between 2000 and 2015 in mortality attributed to major heart disease subgroups including ischemic heart disease, heart failure, and all other types of heart disease.Using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) data system, we determined national trends in age-standardized mortality rates attributed to ischemic heart disease, heart failure, and other heart diseases from January 1, 2000, to December 31, 2011, and from January 1, 2011, to December 31, 2015. Annual rate of changes in mortality attributed to ischemic heart disease, heart failure, and other heart diseases for 2000–2011 and 2011–2015 were compared.Death attributed to ischemic heart disease declined from 2000 to 2015, but the rate of decline slowed from 4.96%  for 2000–2011 to 2.66% (2.00%–3.31%) for 2011–2015. In contrast, death attributed to heart failure and all other causes of heart disease declined from 2000 to 2011 at annual rates of 1.94% (1.77%–2.11%) and 0.64% (0.44%–0.82%) respectively, but increased from 2011 to 2015 at annual rates of 3.73% (3.21% 4.26%) and 1.89% (1.33–2.46%). Differences in 2000–2011 and 2011–2015 decline rates were statistically significant for all 3 endpoints overall, by sex, and all race/ethnicity groups except Asian/Pacific Islanders (heart failure only significant) and American Indian/Alaskan Natives.While the long-term decline in death attributed to heart disease slowed between 2011 and 2014 nationally before turning upward in 2015, heterogeneity existed in the trajectories attributed to heart disease subgroups, with ischemic heart disease mortality continuing to decline while death attributed to heart failure and other heart diseases switched from a downward to upward trend. While systematic efforts to prevent and treat ischemic heart disease continue to be effective, urgent attention is needed to address the challenge of heart failure. We recently reported that the rate of decline of death attributed to total cardiovascular disease (CVD) and to heart disease (HD) in the U.S. had decelerated substantially between 2011 and 2014 .HD-related death encompasses a wide range of heart conditions. Thus, from both prevention and intervention perspectives, it is important to further delineate trends in subcategories of HD-related death. We studied mortality trends in the two largest subgroups of HD (ischemic heart disease [IHD] and heart failure [HF]) and in all other HD combined.International Statistical Classification of Diseases and Related Health Problems, Tenth Edition codes as follows: HD , IHD (I20-I25), HF (I50), and all other causes of HD .Mortality rates between 2000 and 2015 were ascertained using the U.S. Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset, which includes the assigned cause of death from all death certificates filed in the 50 states and the District of Columbia . CategorThis study did not require institutional review board approval because it analyzes government-issued public use data without individual identifiable information.Age-standardized mortality rates (AAMR) were calculated using the direct method, with the 2000 U.S. Census as the standard population using the following age categorization: younger than 1 year, 1 to 4, 5 to 14, 15 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, and 85 years or older [Mortality rates from 2000 to 2015 for HD and HD subgroups are shown in Table , Fig. The rate of decline in death attributed to IHD slowed in 2011–2015, with mean annual rate of change of −2.66% compared to −4.96% for 2000–2011 . Trends in crude mortality rates  for atrial fibrillation and flutter (ICD-10 code I48), and a decrease from 6.8 to 6.3 (p < 0.001) for cardiomyopathy (I42). Changes were not statistically significant for nonrheumatic aortic valve disorders (I35), 4.5 to 4.6 (p = 0.45); and cardiac arrest (I46), 4.4 to 4.3 (p = 0.48).Five specific ICD-10 codes accounted for 63% of deaths attributed to other HD during 2011–2015. There was an increase in age-standardized mortality rates per 100,000 person-years from 9.7 to 11.1 for hypertensive HD (ICD-10 code I11), 5.2 to 6.3  study, although dramatic declines in CVD occurred in regions with high socioeconomic status, only a gradual decrease or no change was noted in most other regions . Of noteThe National Center for Health Statistics recently reported that deaths considered HF-related  declined from 2000 to 2012 but increased from 2012 to 2014 . It is pAnother potential cause of misclassification of HF-related mortality is competing mortality with a non-CVD cause. While it is possible that declining cancer rates could result in the recent increasing trend in HF mortality and this year’s increase in HD mortality, it is unlikely since cancer mortality has been declining at a fairly stable rate of 1.5% per year since 2000 [It is well-recognized that HF is a major and growing public health problem. Earlier estimates from projection models for the U.S. suggest that the prevalence of HF will increase by 46% from 2012 to 2030 . It has While the mortality rate attributed to HD slowed substantially between 2011 and 2014 nationally before turning upward in 2015, trajectories among HD subgroups were heterogeneous, with IHD-related death continuing to decline while death attributed to HF and other causes of HD increased. While systematic efforts to prevent and treat IHD appear to be effective and require continued vigilance, an expanded focus on strategies to reduce deaths from HF and those attributed to other HD conditions appear needed. Finally, addressing the complex care of HF patients with multiple morbidities would likely need system-wide, multipronged health care interventions, with particularly urgent attention to developing more effective treatments for HFpEF .


Knowledge of hepatitis B virus (HBV) genotype is an important predictive variable which might have an impact in management and treatment of patients with chronic hepatitis B infection. In Ghana very little information is available on hepatitis B genotypes. This study was conducted to determine the distribution of HBV genotypes circulating among chronic hepatitis B patients reporting at the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana.Blood samples (10 ml) were collected from 250 consenting patients. DNA was extracted and amplified using polymerase chain reaction technique. Restriction fragment length polymorphism (RFLP) was used for the detection of genotypes.2= 0.923; p-value=0.623) or gender .Out of the 250 chronic hepatitis B patients who were HBsAg positive, 91 (36.4%) were males aged 29.8 ± 9.1 and 159 (63.6%) females aged 33± 12.1 years. HBV DNA was detected in 111 (44.4%) but only 58 (52%) of these were typeable. These were classified as genotype A, 8 (7.2%); genotype D, 3 (2.7%) and genotype E, 47 (42.3%). Our results did not show any association between the infecting genotype and age (XConsistent with similar studies worldwide, the results suggest that genotypes A, D and E were the genotypes circulating among chronic hepatitis B patients who reported to the Korle-Bu Teaching Hospital with genotype E being the most predominant and therefore constitutes an important public health concern. We recommend further epidemiological studies to understand the implication of genotype E in terms of disease progression and treatment. Hepatitis B virus is a DNA virus and the most common among the hepatitis viruses that cause chronic infections in humans. About two billion people globally have been exposed to HBV with approximately 5% of the world’s populations (350 million people) being chronic carriers , of whicHBV infection is emerging in Ghana and autopsy reports have revealed HBV infection to be a major risk factor for developing liver cirrhosis and HCC . KnowledThis cross sectional study was carried out among chronic hepatitis B patients reporting at the KBTH from October 2009 to June 2010.The study was conducted at the Gastroenterology Unit and the Central Laboratory of the KBTH, Accra, Ghana. The KBTH is situated in the nation’s capital, Accra, and it is the leading tertiary hospital and a major referral centre in the country. The Gastroenterology Unit is the biggest tertiary care for hepatitis cases in the country. More than 70% of the total cases in the country receive care and treatment at the Unit.The study subjects were chronic hepatitis B patients. Chronicity of the patients was determined based on their hepatitis B profile data (HBcIgM-negative and HBcIgG-positive). Patients on antiviral therapy for hepatitis B infection and those reporting on repeated visits were excluded from the study. A structured questionnaire was used to obtain socio-demographic characteristics of the subjects after which a blood sample was collected from each participant.Permission was sought from the KBTH authorities and approval granted by the Research and Ethical Review Committee of the Ghana Health Service. Informed consent was also obtained from patients or guardian of the patients before enrollment into the study. Patient’s confidentiality was assured by allocating identity numbers.Blood samples (10ml) were collected from each of the consenting patients in EDTA tubes. Samples were centrifuged and serum kept at -20˚C until analyzed.Total DNA was extracted from plasma of all HBsAg positive kit using the QIAamp DNA Mini kit (Qiagen Co. Ltd UK) in accordance with the manufacturer’s instructions.PCR detection of HBV DNA used was based on the protocol described previously . The priPCR positive products obtained were doubly digested with Hinfl and Tsp5091 (New England BioLabs) restriction enzymes. The HinfI reaction had a total digestion reaction of 15.0 µl containing1.5 µl of X10 buffer, 3.0 µl of nuclease-free water, 0.50 µl of the enzymes and 10 µl of the PCR product. This was incubated at 37˚C for three hours. The Tsp509I reaction also had a total reaction volume of 15.0 µl containing10 µl of PCR products, 1.5 µl of X10 buffer, 2.5 µl of nuclease free water and 1.0 µl of the enzyme. This was also incubated at 65˚C for 3 hours. Ten microlitres of PCR product was mixed with1.5 µl of X10 buffer and 3.5 µl of nuclease free water but no restriction enzymes were run parallel with the enzyme treated sample as controls. The reactions were terminated by adding 4 µl of the loading buffer. A 3% agarose gel containing 0.5 µg/ml ethidium bromide was used to separate the restriction fragment length polymorphism (RFLP) products.Data was entered in Excel and statistical analysis was carried out using STATA (version 10.0) statistical packages. For socio demographic categorical data (e.g sex), summary tables of counts and percentages were presented. For socio demographic continuous data (e.g. age), summary tables of means, standard deviations were presented. Pearson’s chi square test and Fisher’s exact test were used to establish associations between demographic data and various outcome variables. All statistical tests were conducted as two-sided and declared significant for p-value < 0.05.2=0.905; p-value=0.341). We also found that HBV infection to be highest (60%) in both the younger age group (10 - 19 years) and in the older age group of greater than 59 years and the lowest was found in age group 50 - 59 years. These differences were not significant . (Two hundred and fifty (250) chronic hepatitis B patients were enrolled. The participants were 91 (36.4%) males aged 33±12.1 years and 159 (63.6%) females aged 29.3±9.1 years.  shows HB=0.500).  shows th2=0.283, p=0.579). Genotype A and E were predominant in the young patients ages between 20 - 29 years, and genotype D ages between (0 - 9 years), (20 - 29 years) and (30 - 39 years). However, genotypes were absent from individuals aged more than 59 years. This relationship between age and the infecting genotype was however found to be non-significant . No mixed genotypes were found among the study subjects. The distribution of the HBV genotype by age and sex is shown  showed genotype specific bands. The remaining 53 (47.7%) were untypeableas no genotype-specific band were seen. The distribution of the typeable genotypes is as follows: genotype A accounted for 8 (7.2%), genotype D, 3 (2.7%) genotype E, 47 (42.3%). The untypeable accounted for 53 (47.7%). The gel electrophoresis pattern for HBV genotypes obtained after restriction enzyme digest is shown . The preis shown .HBV is endemic in Ghana although there is scarcity of information on HBV genotypes. This study is the first conducted in Southern Ghana profiling the genotypic status of HBV among chronic hepatitis B patients in Ghana. The results of the study revealed that the circulating genotypes were A, D and E. This is in agreement with a study conducted among blood donors by Valente and colleagues in Angola who similarly reported the prevalence of genotypes A, D and E . The finIn our study we could not detect minor subgenotypes and recombinant genotypes because the RFLP technique employed is less sensitive compared to the gold standard genome sequencing technique , 25. ThiOur study has shown the major circulating hepatitis B genotypes among chronic hepatitis B patients reporting to KBTH, Accra to be genotype A, D and E, with genotype E being the predominant. We recommend researchers to conduct similar studies using genome sequencing and further phylogenetic analysis to establish the existence of the minor/subgenotypes or recombinant or novel genotypes and also to determine the effect of these genotypes in the management of chronic hepatitis patients in Ghana.