Objective. Bronchiolitis is one of the commonest causes of hospitalization of infants and young children in Bangladesh. About 21% of under 5 children attending different hospitals of Bangladesh have bronchiolitis. Fifty percent (50%) men and three percent (3%) women of Bangladesh are smokers. Parental smoking is an important risk factor for both susceptibility and severity of bronchiolitis. The aim of this study was to find out the role of parental smoking in severe bronchiolitis. Design. Case-control study. Place and Duration of Study. The study was conducted in the Department of Paediatrics, Sylhet MAG Osmani Medical College Hospital, Bangladesh, from July 2013 to December 2015. Patients and Methods. Sixty-four patients admitted into the ward with severe bronchiolitis were enrolled as cases and sixty-four suitably matched apparently healthy children attending EPI centre and outpatient department presenting with nonrespiratory illness were enrolled as controls. Sample size was calculated using Guilford and Frucher formula. The technique was systematic random sampling. Every second case satisfying the inclusion and exclusion criteria was enrolled in the study. Results. The mean age of the patients was 7.53 (SD ± 4.75) months. Forty (62.5%) patients were male and twenty four (37.5%) patients were female. Male-to-female ratio was 1.7 : 1. Most of the cases (60.95%) came from low socioeconomic background. More than half of the cases (53.13%) were not exclusively breastfed babies. Mean length of hospital stay was 6.41 (SD ± 2.82) days. Thirty eight (59%) cases and twenty six (34%) controls were exposed to parental smoking. Result was highly significant (p = 0.005). Odds ratio was 2.8 (95% CI from 1.36 to 5.72). Conclusion. Exposure to parental smoking causes a statistically significant  increase in the risk of developing severe bronchiolitis in the first year of life.  The age of the patients ranged from 2 to 24 months with the mean age of 7. 53 (±4.75) months. Most frequent age group was 2 to 6 months (50%) followed by 7–12 months (39%) and 13–24 months (11%). Forty (62.5%) cases were male and 24 (37.5%) cases were female. Male-female ratio was 1.7 : 1. Most of the cases (60.95%) came from low socioeconomic background. More than half of the cases (53.13%) were not exclusively breastfed babies. Minimum length of hospital stay was 3 days and maximum was 10 days; mean hospital stay was 6.41 (±2.82) days. Baseline characteristics between cases and controls did not vary significantly regarding mean age (= 0.474) .p value = 0.005, odds ratio 2.8 (95% CI from 1.36 to 5.72). So parental smoking carried 2.8 times risk of developing severe bronchiolitis  had history of only paternal smoking and there was no history of maternal smoking or both. Among 64 controls, 22 had history of exposure to parental smoking. The value was highly significant: hiolitis .The age of the patients ranged from 2 to 24 months: most frequent age group was 2–6 months (50%) with the mean age of 7. 53 (±4.75) months. This finding was quite consistent with a study done at the same institute where the mean age of the patients was 5.5 (±3.83) months . Rida 1 found agSex distribution of the patients  was almost similar to the study of Bashar et al.  who founIn the present study, mean hospital stay was 6.41 (±2.82) days. Kabir et al.  found mep = 0.005, odds ratio 2.8). Jones et al. [p < 0.001) and mechanical ventilation (p < 0.001). Sritippayawan et al. [p = 0.01). Rida [The present study found exposure to parental smoking in 38 59%) cases and 26 (41%) controls . Rida  found exp = 0.00016) than paternal one (p = 0.015). Jurado et al. [In the present study, all exposed cases of severe bronchiolitis (38 out of 64) had history of only paternal smoking and there was no history of maternal smoking or both. Jones et al.  found odo et al.  describeLimitation of this study was not to estimate urinary “cotinine” level. Cotinine, a major metabolite of nicotine, has been used as a biological marker of smoke absorption to strengthen the evidence of exposure to tobacco smokep = 0.005, odds ratio = 2.8) increase in the risk of developing severe bronchiolitis in the first year of life. Protecting young children from parental smoking should be the important approach to prevent the morbidity and mortality caused by severe bronchiolitis.Exposure to parental smoking, particularly paternal smoking, causes a statistically significant (


Chenopodium quinoa Willd.) are usually worthless and little known about their biological activities. In this study, the antioxidant and immunomodulatory potential of the quinoa leaf extracts were explored.Background: Most reports have indicated the antioxidant capacity of quinoa seeds. However, the leaves of Quinoa  scavenging and iron chelating. The total phenolic content was determined. Inhibition of nitric oxide (NO) production in the lipopolysaccharide (LPS)-induced murine macrophage RAW 264.7 cells was examined to gauge the anti-inflammatory activity.ml). The iron chelating activity of the 95% EQL increased in a concentration-dependent manner, which ranged from 10.9% up to 53.9%. The 50% EQL and 95% EQL significantly inhibited NO production in the LPSstimulated RAW 264.7 cells.Results: The 95% EQL showed a higher level of total phenolic content (569.5 mg GAE/g extract) and better DPPH scavenging activity. The WQL exhibited a better iron chelating capacity (28.9% at 10 mg/Conclusion: We demonstrate that the extracts of quinoa leaves possess the biological activities of antioxidant and anti-inflammatory. Our finding suggests that the leaf extract of quinoa has potential to be utilized for natural health products. The natural antioxidants from plant extracts are the subject of increasing scientific interest because of their function in the prevention of disease. Most of the research on the potential effects has been focused on free radical scavenging, metal chelating, anti-inflammation, and anticancer activities , 2. All (Chenopodium quinoa Willd.) is known as a pseudo-cereal and has been found to contain compounds like polyphenols, phytosterols, and flavonoids, all with possible nutraceutical benefits. It is traditionally consumed by the native population of the Andes region -2,5-diphenyltetrazolium bromide (MTT) were purchased from Gibco . Ethanol  was purchased from ECHO Chemical Co., Ltd. . Quinoa plants were grown in a temperature-controlled greenhouse. Fully expanded leaves of quinoa were harvested and freeze-dried for 24-h. The dried sample was ground into powder using a kitchen milling machine and stored at -20°C prior to extraction.2.2.ml of distilled water, 50% and 95% ethanol for 16-h at room temperature, and the solid-liquid mixture was filtered through Whatman No.2 filter paper . The resulting supernatant was concentrated under a vacuum at 40°C  and freeze-dried for 24-h to obtain the crude extracts. The dried water extract was dissolved in PBS, denoted WQL. Dried extracts of quinoa leaves using 50% and 95% ethanol were dissolved in DMSO and named 50% EQL and 95% EQL, respectively. The stock solutions of 100 mg/ml were stored at -20°C prior to determining the antioxidation activity and the inhibition of NO production.The quinoa leaf powder (1 g) was extracted with 50 2.3.ml) was mixed with 2.5 ml of Folin’s reagent (diluted with distilled water 1:10) and 2 ml of 7.5% (w/v) sodium bicarbonate solution. Their absorbance was determined spectrophotometrically at 760 nm using a microplate reader  after standing for 30 min at room temperature. The results were expressed as milligram gallic acid equivalent (GAE) per gram extract.The total phenolic contents of WQL, 50% EQL and 95% EQL were determined by the Folin-Ciocalteau assay . Each di2.4.et al. [Acontrol - Asample) / Acontrol] × 100%, where Acontrolis the absorbance of DPPH solution without extract and Asample is the absorbance of the sample with DPPH solution.The DPPH radical-scavenging activity of all crude extracts of quinoa leaves was determined according to the method of Shimada et al.  with sli2.5.et al. [2 was added to 0.25 ml of different concentrations of the crude extract  and 0.05 ml of 5 mM ferrozine solution. The mixture was vigorously shaken and allowed to stand at room temperature for 10 min. The absorbance of the solution was thereafter measured at 562 nm and the inhibition percentage of ferrozine–Fe2+ complex formation was calculated as the same as the DPPH method described above.The chelation of ferrous ions by quinoa leaf extracts was estimated using the method reported by Dinis et al. . Briefly2.6.2.The murine macrophage RAW 264.7 cell line was a gift from Dr. Yuan-Yen Chang. The cells were cultured in RPMI 1640 supplemented with 10% FBS and 1% antibiotic antimycotic solution at 37°C in a humidified incubator under 5% CO2.7.4 cells/well and allowed to adhere for 24-h before treatment. Next, cells were treated with various concentrations of WQL, 50% EQL, and 95% EQL, respectively. After 24-h incubation, MTT was added to a final concentration of 0.5 mg/ml and the cells were incubated for 2-h at 37°C. The medium was then removed and 150 ml of DMSO was added to dissolve the formazan precipitate. The absorbance was measured at 570 nm using a microplate reader . The cell viability was normalized to the medium control group and expressed as % of control. The non-cytotoxic dose of all crude extracts was determined to be 1-100 μg/ml, and 1, 10 and 100 μg/ml of all crude extracts were used for exposure in the subsequent experiments.Cell viability was determined by the MTT assay. Briefly, cells were seeded in a 96-well plate at a density of 5 × 102.8.4 cells/well) were treated with WQL, 50% EQL, and 95% EQL at a final concentration as described in the previous section. After a 1-h treatment, cells were stimulated with 1 μg/ml of LPS for 24-h. Nitrite content in cell culture media was determined by the Griess reaction. Briefly, 100 μL of the conditioned media with an equal volume of Griess reagent  in a 96-well plate was incubated at room temperature for 10 min. The absorbance at 540 nm was determined by a microplate reader . The production of nitrite was calculated from a sodium nitrite (NaNO2) standard curve.Cells in 96-well plates  using oneway ANOVA followed by Duncan’s test. Values were considered significantly different when 3.3.1.The total phenolic content of the crude extract of quinoa leaves is shown in 3.2.ml, the 95% EQL exhibited the highest level of DPPH radical scavenging activity, which were 50.7 ± 9.7% and 65.3 ± 4.7%, respectively.The radical scavenging ability of the crude extracts of quinoa leaves was measured using the DPPH scavenging assay. The results showed that the 50% EQL and 95% EQL were able to scavenge DPPH radicals in a concentration-dependent manner . In the 3.3./ml, the WQL showed a significantly higher iron chelating ability (28.9 ± 2.8%) than the 50% EQL and 95% EQL (/ml than their counterparts at 10 mg/ml and 100 mg/ml.In the concentration of 10 mg 95% EQL . The lev3.4.ml) of WQL, 50% EQL, and 95% EQL for 1-h and then exposed simultaneously to 1 μg/ml LPS for 24-h, the cell viability was determined by MTT assay. The cell viability was not influenced by the quinoa leaf extracts and LPS treatment  for 1-h, the inhibition of the LPS-induced NO production ranged from 10.2% to 38.1%  [2+ chelating potential in spite of its low DPPH activity. This observation suggests that the use of different methods is necessary to measure the antioxidant potentials of plant extracts.The results of the present study demonstrated that the crude leaf extracts of quinoa exhibited chelating activity by reducing the formation of ferrozine-Fexidation . Gawlik-nd AT-2) . The quiUnder normal physiological conditions, NO acts as a necessary component in the regulation of various physiological functions such as blood pressure, immune response, and neural communication . However5.in vivo are required to confirm these findings.The results of the present study indicated that the 95% EQL contained the highest amount of total phenolic content and provided the greatest DPPH scavenging activity among all extracts, as well as inhibited NO production in LPS-induced RAW 264.7 cells. Our results suggest that quinoa leaves are a valuable bioactive natural product for dietary supplementation. Further studies The authors declare no conflicts of interest.


Accelerated treatment strategy, including tight disease control and early aggressive therapy with immunosuppressives (IS) and biological agents have become increasingly common in inflammatory bowel disease (IBD). The aim of the present study was to estimate the early treatment strategy and outcomes in newly diagnosed patients with Crohn’s disease (CD) between 2004 and 2008 and 2009–2015 in the whole IBD population in Hungary based on the administrative database of the National Health Insurance Fund (OEP).We used the administrative database of the OEP, the only nationwide state-owned health insurance provider in Hungary. Patients were identified through previously reported algorithms using the ICD-10 codes for CD in the out-, inpatient  non-primary care records and drug prescription databases between 2004 and 2015. Patients were stratified according to the year of diagnosis and maximum treatment steps during the first 3 years after diagnosis.p = 0.001), anti-TNF: 73%vs. 66.7% (p = 0.103), IS: 64.6% vs. 56.1% (p = 0.001), steroid: 44.2%vs. 36.8% (p < 0.007), 5-ASA: 32.6% vs. 26.7% p = 0.157)). In contrast, surgery rates were not significantly different in patients diagnosed before and after 2009 according to the maximum treatment step  anti-TNF 26.7%vs.27.2% (p = 0.993), IS: 24.1%vs22.2% (p = 0.565), steroid 8.1%vs.7.9% (p = 0.896), 5-ASA 10%vs. 11% (p = 0.816)).A total of 6173  newly diagnosed CD patients with physician-diagnosed IBD were found in the period of 2004–2015. The use of 5-ASA and steroids remained common in the biological era, while immunosuppressives and biologicals were started earlier and became more frequent among patients diagnosed after 2009. The probability of biological therapy was 2.9%/6.4% and 8.4%/13.7% after 1 and 3 years in patients diagnosed in 2004–2008/2009–2015. The probability of hospitalization in the first 3 years after diagnosis was different before and after 2009, according to the maximal treatment step (overall 55.7%vs. 47.4% (IS and biological exposure became more frequent, while hospitalization decreased and surgery remained low but constant during the observation period.Use of steroids and 5-ASA remained high after 2009. The association between the maximal treatment step and hospitalization/surgery rates suggests that maximal treatment step can be regarded as proxy severity marker in patients with IBD. Inflammatory bowel diseases (IBD) are chronic conditions affecting the patient’s quality of life, leading to disability; moreover, a significant proportion of patients require surgery. In the past decades, the prevalence of IBD increased worldwide –3. HowevThe recent ECCO-EpiCom studies based on the 2010 and 2011 inception cohorts provided data about up-to-date IBD incidences, treatment steps and initial disease course of IBD in the biological era in Europe. Differences were reported between Western and Eastern Europe, not only in the prevalence of IBD, but also regarding treatment strategy and disease outcomes . Data onIn Hungary, previous population-based studies on the epidemiology and treatment strategy in IBD were reported in the Veszprem population-based IBD database. Nevertheless, data on medical strategy were reported from the pre-biological era , 17. RecTherefore, the aim of the present study was to investigate the early treatment strategy and outcomes in newly diagnosed patients with Crohn’s disease (CD) between 2004 and 2015 in Hungary. Since the prescription regulations changed significantly at the end of 2008 with easier access to biologicals, it has been aimed to evaluate surgical outcomes and hospitalization rates before and after the change of prescription-regulations in the administrative database of the National Health Insurance Fund (OEP) which is the only (state-owned) health insurance provider in Hungary.We used the administrative database of the National Health Insurance Fund (OEP). Patients were identified through previously reported algorithms using the ICD-10 codes for Crohn’s disease (K50..) in the out- and inpatient  non-primary care records and drug prescription databases between 1st of January 2004 and 1st of January 2015 . HospitaNew patients with Crohn’s disease was defined as no CD-related outpatient visits and/or IBD-related drug prescriptions in the last 3 years before the start of the observational period and at least 2 CD-related outpatient visits and/or IBD-related drug prescription during the observational period. Patients with less than 3 years follow up were excluded from the study. Patients were stratified according to the year of diagnosis and the maximum treatment step during the first 3 years after diagnosis.We determined time to prescription of different drug classes,  and stratified patient groups according to the maximal therapeutic step , 2. group – maximum therapeutic step: steroid therapy , 3. group – maximum therapeutic step: IS therapy , 4. group – maximum biological therapy ). Finally, we calculated hospitalization and surgery rates according to the maximal treatment step and the diagnostic period (diagnosis in 2004–2008 vs. 2009–2015).p value of < 0.05 was regarded as statistically significant.SPSS® 20  was used for statistical analysis. Khi-square test and Fischer-exact tests were used to compare categorical variables. Kaplan-Meier analysis and Cox-Mantel LogRank test was used for time dependent change of the categorical variables. Time from diagnosis were weighted to 30-days periods in the Kaplan-Meier analysis. A A total of 6173  newly diagnosed CD patients with physician-diagnosed Crohn’s disease were found between 2004 and 2015. 4458 and 1715 newly diagnosed CD patients with an available 3-year follow up period were identified between 01.01.2004 and 31.21.2008 and between 01.01.2009 and 01.01.2015. Distribution of age at diagnosis was similar in the two diagnostic eras, the most prevalent age group at the diagnosis of Crohn’s disease was the 20–29 years old group in both gender and in both diagnostic eras . Probability of early steroid exposure was different according to the maximum treatment step but not according to the year of diagnosis: it was 48.9%/53.5% after the first 3 months from diagnosis in patients with steroids as maximum treatment step (pLogRank = 0.09), 74%/74.8% in patients with IS as maximum treatment step (pLogRank = 0.95) and 81.2%/78.7% in patients with biological therapy as maximum step (pLogRank = 0.31), in patients diagnosed before and after 2009  and earlier initiation in the second period. Probability of immunosuppressive therapy was 17.5% vs. 22.9% at 3 months, 29.3% vs. 35.4% at 1 year and 39.9% vs. 45.2% at 3 years in 2004–2008 vs. 2009–2015 in patients with IS as maximum treatment step. Exposure of IS was higher in patients needing anti-TNF therapy: 31.5% vs. 40.3% at 3 months, 66.7% vs. 73.1% at 1 year and 86.7% vs. 91.8% at 3 years in 2004–2008 vs. 2009–2015 . It was 1% vs. 1.2% after 3 months, 2.9% vs. 6.4% after 1 year and 8.4% vs. 13.7% after 3 years in 2004–2008 vs. 2009–2015 . When we analysed the hospitalization rates according to the maximal treatment steps, the difference was significant in the steroid and IS group   in both diagnostic eras, regardless of the maximum treatment step . Thereafter the probability of surgery remained unchanged in patients with 5-ASA and steroid only, while it increased continuously in the IS and biological group , biological therapy: 26,7% vs. 27.2% (pLogRank = 0.993), IS: 24.1% vs. 22.2% (pLogRank = 0.565), steroid 8.1% vs. 7.9% (pLogRank = 0.896), 5-ASA 10% vs. 11% (pLogRank = 0.816) in patients diagnosed in 2004–2008 vs. 2009–2015)  had surgery at around the diagnosis (within 3 months from diagnosis) in both diagnostic eras, independently from the maximum treatment step and further disease course. Similarly, Solberg et al. reported that very early CD-related surgery rates remained unchanged and did not influence long term clinical remission rates or outcomes . In contFurthermore, our results suggest that the earlier and more frequent use of biological therapy did not reduce the probability of early surgery during the first 3 years from diagnosis. Previous population-based studies reported that the need for surgery significantly decreased between the 1980s and 2000s, parallel with the increased use of immunosuppressives , 8, 22. The probability of hospitalization was frequent around the diagnosis, but thereafter the frequency of hospitalization was not associated with the maximal therapeutic steps in the present study. Frequency of hospitalization was lower in all treatment groups in the second diagnostic period (decrease was significant in the steroid and IS group), showing a change in the patient management and the possible role of the accelerated treatment strategy. These results are in concordance with previous data that hospitalization is frequent around the diagnosis but it declines significantly from the second year after the diagnosis , 28. NevThe other primary aim of the study was to analyse the therapeutic strategy in the two diagnostic eras. Surprisingly, almost every CD patient received 5-ASA therapy in Hungary at around the diagnosis. This result is in concordance with the result of the ECCO-EpiCom 2011 inception cohort study and with other nationwide studies , 14. PosInterestingly, the use of steroids remained common in both periods. The majority of patient received steroid therapy as initial treatment at diagnosis and it increased slightly over time. Compared to other recent population-based studies, the use of steroids was more frequent in the present cohort. In previous population-based studies the half of the CD patients received steroids during the early disease course , 30, 31.The use of immunosuppressives was more frequent in the second period with earlier initiation. This suggests an accelerated step-care strategy in Hungary, similarly to those reported from the Spanish Administrative Database . In the Finally, the use of biologicals was more frequent with earlier initiation in the second period in accordance with the changes of the drug prescription guidelines of OEP allowing an earlier and more extensive availability of anti-TNFs after 2009 in Hungary. In a previous study by Rencz et al. Hungary had the best access to biologicals in IBD in Central-Eastern Europe . HoweverThe authors are aware of the possible limitations of the present work including the limitations of administrative databases such as the lack of disease phenotype data, time bias due to patient stratification or possible bias of patient ascertainment. In contrast, the strength of the present study is the nationwide nature of the study. The administrative database of the National Health Fund is unique in many regards, as in Hungary this is the only insurance plan with a full coverage and it collects in-, outpatient visits, diagnostic procedures and drug prescription data. Thus, it offers an invaluable opportunity to study treatment practices and changes in outcomes representative for the full spectrum of IBD patients in Hungary. Moreover, earlier publications suggested that the first 3-years of the disease are the most sensitive and representative for the further disease course , 34. ThuIn conclusion, the present study, representing the nationwide practices in Hungary suggests, that there is an accelerated therapeutic strategy in CD in Hungary with IS and biological use becoming more frequent. Hospitalization decreased in the whole cohort, while surgery remained low but constant during the observation period.Exposure to steroids and 5-ASA remained high. The association between maximal treatment step and hospitalization and surgery rates suggests that maximal treatment steps can be regarded as proxy severity markers in patients with IBD.


Thyroid incidentalomas (TI) are highly prevalent asymptomatic thyroid nodules with ultrasound as the best imaging modality for their detection and characterization. Although they are mostly benign, potential for malignancy is up to 10–15%.In sub-Saharan Africa little data exists on the prevalence and risk categorization of TI. The aim of this study was to determine the prevalence and ultrasound characteristics of non-palpable thyroid incidentalomas among adults in sub-Saharan setting.p-value < 0.05.A cross sectional study was carried out between March and August 2015, at two university teaching hospitals. Sampling was consecutive and included all adults aged ≥ 16 years, presenting for any ultrasound other than for the thyroid, with no history or clinical signs of thyroid disease, and no palpable thyroid lesion. Ultrasound was done using 4 to 11 MHz linear probes. Subjects with diffuse thyroid abnormalities were excluded. Variables studied were age, gender, thyroid volume, ultrasound characteristics of thyroid nodules, TIRADS scores. Differences were considered statistically significant for p < 0.001). Of the 241 TI found, 49.4% were cysts, 33.6% solid, 17.0% mixed; 37.8% <5 mm and 22% >10 mm. Solid TI were mainly hyperechoic (42.0%), 3/81 were markedly hypoechoic. Sixty-nine out of 126 persons with TI (54.8%) had at least two nodules. Solitary nodules were predominant in the age group ≤20 years. Of 241 TI, 129 (53.5%) were classified TIRADS 2, 81 (33.6%) TIRADS 3, 25 (10.4%) TIRADS 4A, 6 (2.5%) TIRADS 4B, and none TIRADS 5. Characteristics associated with increased risk of malignancy where mostly founded on solid nodules (p < 0.000) and nodules larger than 15 mm (p < 0.001).The prevalence of TI was 28.3% (126 persons with TI /446 examined). This prevalence was 46.2% in population ≥ 61-year-old; 6.3% in population ≤ 20-year-old; 33.3% for females and 18.4% for males (Thyroid incidentalomas were very frequent with a prevalence of 28.3% and potential risk of malignancy in 12.9%. Prevalence had a tendency to increase with age and in female. Cystic nodules were the most prevalent. Potential for malignancy would be increased for larger and solid nodules. Thyroid incidentalomas (TIs) are asymptomatic nodules discovered accidentally during imaging studies indicated for other reasons . UltrasoTIs therefore represent a clinical challenge and a source of anxiety to patients. The clinician needs to correctly access the risk of each nodule, in order to correctly determine if and what further investigation is necessary. The TIRADS (Thyroid Imaging Reporting and Data System) permits this classification with recommendations on the need for cytologic verification or ultrasound surveillance , 9, 10.In sub-Saharan Africa little data exists on the prevalence and risk categorization of TI . The aimA cross-sectional study was carried out in two university teaching hospitals from March to August 2015.Persons aged ≥ 16 years, referred to the diagnostic imaging department for ultrasound scans other than that of the thyroid, who accepted freely to participate in the study were included. They had no history, palpable or other clinical signs of thyroid disease. A consecutive non-probabilistic sample was taken. Patients with diffuse thyroid disease were excluded. Verbal informed consent from participants was required.Prosound alpha 6  2015 and SSI-8000  2013. Images were stored in the hard drive of each machine. An initial interpretation was done by the operator during the course of the scan. A second reading was done later by the operator and two radiologists with at least five years’ experience in thyroid sonography. Nodules were classified by consensus according to TIRADS , and TIRADS score for each TI. The CSPro 5.1 software was used to create the data entry mask anonymously. Stata version 11 and SPSS version 18 software enabled the analysis of the data. The chi square test assessed the association between the TIRADS score and various socio-demographic and sonographic characteristics. The comparison of the prevalences were performed using the Fisher exact test. Results were expressed in numbers and percentages for categorical variables. Differences were considered statistically significant for Four hundred and forty six subjects aged 16 to 89 were included, with 294 females . The most frequent age groups was 21–40 years with 48.7% (Table p < 0.001) and 46.6% in individuals aged more than 60 years  having two or more TI  in the right lobe and 3.7% in the isthmus (9 cases). Most were inferiorly (base) located 38.2% (92/241), followed by location within the corpus (31.1%).Of the 241 TIs, cystic nodules accounted for 49.4%; solid nodules for 33.6%; mixed (cystic and solid) for 17.0%. According to size 37.8% TIs were <5 mm and 22% >10 mm (Table In regard to solid nodules (81/241), 42.0% were hyperechoic, 29.6% isoechoic, 24.7% with moderate hypoechogenicity and 3.7% were markedly hypoechoic. 39 solid TIs had a peripheral hypoechoic ring.Solid and mixed incidentalomas had well defined borders in 91.0% of cases; ten nodules (8.2%) had indistinct borders. Eight nodules had macrocalcifications, two had microcalcifications. Half of them did not show any form of vascularization on Doppler examination (pulse and power). Peripheral vascularization was seen in 39.3% of cases (48/122). Only one nodule presented predominantly central vascularization.Of 241 TIs, 129 53.5%) were classified TIRADS 2 . None was cystic : Table There was no significantly strong association between age, gender and TIRADS score. Prevalence of potentially malignant nodules (TIRADS 4) increased with size , than males (18.4%). This has been also reported by authors in Nigeria [Prevalence of TIs was significantly higher in females . This result was similar to the previous reports , 11, 16.Almost half of TIs were cystic in nature (49.4%) in line with other studies , 10, 11.p < 0.000): of the 31 nodules classified TIRADS 4, 77.4% were solid and 22.6% of mixed echogenicity. Solidity of nodules is considered suspicious of malignancy in the TIRADS classification, as opposed to purely cystic and spongiform nodules. There is also an association between size and risk of malignancy (p < 0.001), the prevalence of potentially malignant nodules increases with size . This reiterates the need for cytological examination of nodules > 10 mm whereas those < 5 mm do not need this [We had similar prevalence of TIRADS 2 nodules (54.5%) as Olusola-Bello and al (54.0%) in Nigeria ; these tWe did not find an association between the TIRADS score and age or sex. Capelli and al did not find a significant difference in the prevalence of malignant nodules among the two sexes . Kim andThere were some limitations in this study: first this study was conducted in a hospital-based setting; and second no cytological analysis of nodules was performed because participants were either reticent to do so, or lost to follow up. A community based study may better determine the true prevalence of thyroid incidentalomas in the general population.Thyroid incidentalomas were very frequent with a prevalence of 28.3% and a potential risk of malignancy in 12.9%. Prevalence had a tendency to be increased with age and female sex. Purely cystic nodules are the most frequent. Risks of malignancy would be increased for a larger size and would be higher for TIs of solid components.


Setting V20=29.03% as the cut-off value, the prediction of RILI achieved high accuracy (94.5%), with a sensitivity of 80% and specificity of 96%. The NTCP model parameters for 109 patients were m=0.437, n=0.912, and TD50(1)=17.211 Gy. The sensitivity of the modified Lyman NTCP model to predict the RILI was 90% (9/10), the specificity was 69.7% (69/99), and the accuracy was 71.6% (78/109). The RILI rate of the NTCP<9.62% in breast cancer patients was 1.43% (1/70), but the RILI rate of the NTCP>9.62% in patients with breast cancer was 23.08% (9/39), (P=0.001). In conclusion, V20 is an independent predictive factor for RILI in patients with breast cancer treated by IMRT; V20=29.03% could be a useful dosimetric parameter to predict the risk of RILI. The Lyman NTCP model parameters of the new value  =17.211 Gy) can be used as an effective biological index to evaluate the risk of RILI.To investigate the relationship between dosimetric factors, including Lyman normal-tissue complication (NTCP) parameters and radiation-induced lung injury (RILI), in postoperative breast cancer patients treated by intensity modulated radiotherapy (IMRT). 109 breast cancer patients who received IMRT between January 2012 and December 2013 were prospectively enrolled. A maximum likelihood analysis yielded the best estimates for Lyman NTCP parameters. Ten patients were diagnosed with RILI (primarily Grade 1 or Grade 2 RILI); the rate of RILI was 9.17% (10/109). Multivariate analysis demonstrated that ipsilateral lung V Breast cancer is the most common cancer of women worldwide –3. As inIn recent years, intensity-modulated radiation therapy (IMRT) has achieved a good curative effect in the treatment of breast cancer. In the process of breast cancer radiotherapy, lung tissue is affected by the dose of irradiation, resulting in radiation-induced lung injury (RILI) of different degrees. The main manifestation of RILI is acute radiation pneumonitis (RP) or chronic pulmonary interstitial fibrosis (PF) . RILI isSome studies have suggested that factors including age, gender, pulmonary function, lung irradiation volume and the use of chemotherapy were associated with RILI . The norP > 0.05), while the number of chemotherapy cycles was significant . More details are shown in Table From January 2012 to December 2013, a total of 109 patients met the inclusion criteria; the median follow-up time was 13 months (6 to 26 months). Patients were diagnosed with breast cancer at ages ranging from 29 to 73 years old; the median age at diagnosis was 45 years. The patients were divided into two groups based on whether RILI developed. The absence of RILI group included 99 cases, while the RILI group comprised 10 cases; the incidence was 9.17%. There were 4 cases of acute grade 1 RILI and 4 cases of acute grade 2 RILI, which occurred within the first 6 months after radiotherapy; the symptoms resolved after treatment with antibiotics and high-dose hormones. No patients experienced grade 3, 4 or 5 acute RILI. Chronic RILI was reported in 2 cases: one in grade 2 and one in grade 3. Chronic RILI occurred more than 6 months after radiotherapy. The incidence of RILI was independent of the age of patients, operation method, and clinical stage (P < 0.05), ipsilateral lung V5 , V10 , V15 , V20 , V25  and the occurrence of RILI were analysed; the results are shown in Table The average volume of ipsilateral lung , Table 20 could predict RILI with an area under the ROC curve (AUC) of 0.909. The AUC of 95% CI was 0.798 to 1.000, and V20 of 29.03% was the best cut-off point; the sensitivity of the prediction of RILI was 80%, and the specificity was 96%  = 17.211 Gy. The relationship between the mean dose and NTCP in the 109 breast cancer patients in the ipsilateral lung is shown in Figure p = 0.001), Figure As shown in Figure 20 less than 30% is safe [P > 0.05). Considering the effect of a small number of cases or short follow-up time, the clinical staging and operation effect on RILI manifested no statistical significance.RILI includes early acute radiation pneumonia and late chronic radiation pulmonary fibrosis . Clinica is safe . Some st is safe , 15, 16. is safe , 17. Oth is safe . Our stu20, mean dose of normal lung (MLD) and other dosimetric parameters are predictive of RILI. When MLD≤17 Gy, V20≤31.0%, and V30≤24.0%, the probability of severe RILI will be 0-10.7% [20 for level 1 and level 1 above a meaningful forecast, RILI, MLD and V20 are associated with grade 2 or greater RILI. Graham et al. [20 is the most important factor that affects RILI; when V20 < 22%, no RILI occurs, when V20 is between 22% and 31%, 32% and 40% and > 40%, the 24 month RILI incidence is 7%, 13% and 7%, respectively. At the same time, when V20 is between 22% and 31%, 8% of patients have 2nd level RILI, while 3rd level radioactive pneumonia occurs when V20 ≥ 32%. Asakura et al. [20 is an independent risk factor in patients with oesophageal synchronous chemotherapy; when V20 < 24%, the incidence of RILI is 13%, when 25% < V20 < 36%, the rate is 33% and when V20 ≥ 37%, the incidence is 78%. Additionally, some scholars demonstrated that in normal lungs, MLD and the occurrence of RILI also showed a positive correlation; here, with the increase of MLD, the incidence of RILI also gradually increased. Roeder et al. [5-V25 had obvious differences (p < 0.05); the logistic regression analysis showed that V20 had the closest relationship with RILI. When V20 > 29.03%, the incidence of RILI was 66.67%, and V20 acuities were 29.03% when the incidence of RILI was 2.06%; the difference between the two was statistically significant (p = 0.000). The results suggest that V20 can serve as a predictor of RILI occurrence and evaluate the merits of the radiotherapy plans. Therefore, according to V20≤29.03%, the parameter values for predicting the occurrence of RILI can effectively reduce the incidence of RILI and improve the quality of life in breast cancer patients.The lung V 0-10.7% , 20. Cla 0-10.7%  reportedm et al.  found tha et al.  found thp < 0.05). This study does not provide a detailed analysis of the impact of different chemotherapy regimens on RILI because the selected cases were included for various reasons . However, chemotherapy failed to enter the multivariable analysis. The logistic regression model is the main reason that the research analysis may have not considered the interactions between all factors, ignoring the influence between them.The lung injury induced by chemotherapy drugs and RILI can produce superimposed effects . Theuws 50 of the lung values to be 0.87,0.18, and 24.5 Gy, which have a large volume effect on RILI [n = 0.912, m = 0.437, TD50(1) = 17.211 Gy, and NTCP = 9.62% as the diagnostic values; the model to predict the sensitivity of RILI was 0.9(9/10), with a specific degree of 0.697(69/99), and an accuracy of 0.716 (78/109). In 109 breast cancer patients, NTCP < 9.62% of patients showed an incidence of RILI of 1.43% (1/70), which was far lower than the NTCP ≥ 9.62% of breast cancer patients, who had a RILI incidence rate of 23.08% (9/39), suggesting that the model had a good prediction effect on RILI. Tsougos analysed the NTCP model and found its predictive value in non-small cell lung cancer patients with RILI [The Lyman NTCP model is derived from the DVH graph for mathematics-related data to calculate the probability of complications after radiotherapy in patients. In 1991, Burman found the Emani data value fitting model parameters n, m, and TD on RILI ; this al on RILI ; for theith RILI ; if the n = 0.912, TD50(1) = 17.211 Gy) can be used as an effective index to evaluate the risk of occurrence of RILI. In addition, V20 was an independent predictive factor for RILI in patients with breast cancer treated by IMRT. V20 = 29.03% could be a useful dosimetric parameter for evaluating the risk of RILI.In conclusion, NTCP could be used for the evaluation of the radiotherapy target in the optimization of IMRT. The Lyman NTCP model parameters of the new value  female patients who underwent breast cancer surgery in the hospital with breast cancer confirmed by postoperative pathology diagnosis; (2) age from 25 to 75 years old; (3) Karnofsky score  ≥ 70 points; (4) no smoking history; (5) patients who underwent IMRT for the first time; (6) no concurrent chemotherapy and endocrine therapy during radiotherapy; and (7) patients completed radiotherapy and were followed-up for more than 6 months. Exclusion criteria: (1) patients with tumour recurrence or distant metastasis; (2) patients with concurrent heart or lung disease; (3) patients who could not tolerate radiotherapy or failed to complete radiation therapy for any reason. This study was approved by the Institutional Review Board of Cancer Hospital of Guangxi Medical University, which required informed consent.−1, 5f/W). The supraclavicular region was used, and exposure of the whole breast was prevented with axillary equipment. The breast tumour bed synchronous dosage was 10-16 Gy/1-1.5 W  in patients with invasive breast cancer and negative margins; the breast tumour bed boost was 16-20 Gy/1.5-2 W  in patients with invasive breast cancer and positive margins. After modified radical mastectomy for breast cancer, the radiotherapy dose was as follows: using 6 MV X-ray irradiation . All patients who underwent modified radical mastectomy had treatment of the chest wall surface using a 0.5 cm thick film pad when irradiated equivalent to 20 Gy, and then the equivalent film was removed when irradiated to 50 Gy. The treatment plan required that 95% of the target dose covered the target volume of 100%, and the maximum dose was less than 110% of the prescribed dose. The PTV dose and organ damage limits were: ipsilateral lung, V20 < 30%, Dmean < 20 Gy; bilateral lung, V20 < 20%; heart (only left-sided breast cancer patients), V30 < 10%, V40 < 5%; and contralateral breast, Dmean < 1 Gy, Dmax < 5 Gy.IMRT was performed using a vacuum pad in a fixed position. The CT scan imaging system was networked with the radiotherapy planning system, delineating clinical target volume (CTV) and organ at risk (OAR), including spinal cord, heart, lung and contralateral breast. The planning target volume (PTV) is an extension of CTV. The dose of radiotherapy after breast-conserving surgery was as follows: whole breast irradiation with 6 MV X-rays, with a total dose of 50 Gy/5 W , acute and chronic RILI can be divided into 5 levels based on standard RILI evaluation . After r5, V10, V15, V20, V25, V30, V35, V40, and V45  were prospectively collected.RILI-related clinical factors such as age, clinical operation, tumour stage, number of chemotherapy cycles and physical parameters, including the planning target volume (PTV), ipsilateral lung and bilateral lungs volume, bilateral lungs, ipsilateral lung and contralateral lung maximum dose, mean dose, and lung VThe Dose Volume Histogram (DVH) data for each patient were transferred to MATLAB  software. The data were fitted using the Lyman-Kutcher-Burman (LKB) NTCP model , 13, 32.50, a steepness parameter, m, and the volume exponent, n . While TD50 is strongly dependent on the grade of RP being considered, n is often regarded as a tissue characteristic. The Newton-Raphson method was used to calculate m, n, TD50 and maximum likelihood parameter estimation by MATLAB [The Lyman NTCP model only considers uniform illumination; the radiation dose of normal lung radiotherapy in breast cancer is not uniform, with Kutcher-Burman equivalent volume calculation method used to normalize non-uniform dose-distribution (DVH plots) converted into equivalent uniform distribution . An equiy MATLAB , 13, 32.2 test and multivariate analysis using the logistic regression model. Receiver operating characteristic (ROC) curve analysis of ipsilateral lung volume percentage was in relation to the RILI. In each case, the NTCP value with the Lyman-Kutcher-Burman model was calculated; the relationship between the parameters and the occurrence of RILI was analysed using the t test, and the difference between the two groups in the model parameters was compared using the t test. Receiver operating characteristic (ROC) curve analysis of the new Lyman model was performed to calculate the relationship between the NTCP value and RILI. P < 0.05 was considered statistically significant.SPSS22.0  statistical software was used for analysis. Univariate analysis using the t test and χ


Premature ovarian insufficiency leads to through infertility and estrogen deficiency. Optimal management encompasses estrogen replacement therapy. Long-term outcome of women with POI is not known. We design a study to evaluate the medical care, hormone replacement therapy compliance and bone mineral density (BMD) in POI women with at least a five-year follow-up after the first evaluation. One hundred and sixty-two patients (37.3±8.0 years) were evaluated (follow-up 7.9±2.8 years). Sixty-nine patients (42.6%) had stopped their hormone replacement therapy (HRT) for at least one year during the follow up period. BMD determination at initial evaluation and at follow-up visit was completed in 92 patients. At first evaluation, 28 patients (30%) had osteopenia and 7 (8%) had osteoporosis. At follow up, 31 women (34%) had BMD impairment with osteopenia in 61% and osteoporosis in 5%. In univariate analysis and multivariate analysis, there was a significant loss of femoral BMD in women who had stopped their HRT for over a year. In conclusion, this first study concerning long-term follow-up of POI patients shows the poor compliance to their HRT, despite its importance in the prevention of bone demineralization. This study reinforces the need for follow up and specific care for POI women. Premature ovarian insufficiency (POI) is a disorder affecting approximately 1% of women under 40 years of age . AlthougBesides impairing the quality of life through infertility and estrogen deficiency, the long-term outcome of these women is actually not known. Indeed, most women with POI experience sustained sex steroid deficiency for longer periods compared with women who experienced spontaneous menopause around middle age. The long-term effects of POI are extrapolated from studies on the age of menopause onset, the consequences of prophylactic bilateral oophorectomy or Turner syndrome –9. TheseWe therefore conducted a longitudinal study of POI women, with at least five years of follow up after their first evaluation. To investigate the evolution of this disorder, we assess the initial and follow up medical managment, bone health status and hormone replacement therapy (HRT) use of POI patients.A cohort of POI patients was set up in our department in 2001. As described in detail previously , it inclWe designed a cross-sectional study of patients with POI, at least five years after a first evaluation in our department . POI pat® Immunotech, Beckman-Coulter from 2006 to 2009 and EIA AMH /MIS® Immunotech, Beckman-Coulter from 2009 to 2014. Samples collected before 2006 were frozen at -20 C until assay. The intra- and interassay coefficients of variation for AMH determination were 5.3 and 8.7%, respectively. The AMH assay sensitivity was 0.05 μg/l. In women with normal menstrual cycles, the normal range for day 3–5 of the cycle is 2.2–6.8 μg/l. Plasma TSH was measured by immunofluorometric assay . The interassay coefficient of variation was 1.7 to 2.9%. The detection limit was 0.01 mIU/l. Plasma PTH was measured by immunofluorometric assay . The interassay coefficient of variation was 6.2 to 8.5%. The detection limit was 6 pg/ml. Plasma 25OH Vitamin D was measured by immunofluorometric assay . The interassay coefficient of variation was 8.5 to 10.9%. The detection limit was 4 ng/ml.LH, FSH, Estradiol, inhibin B and AMH were measured as described in detail previously . Serum A1–L4) were evaluated and expressed as absolute values in g/cm2 and T-scores ((BMD–peak bone mass)/S.D). OFELY Caucasian reference curves were used to calculate the women's T-scores  for quantitative variables and numbers (percentages) for qualitative ones. Comparisons between two groups were performed using Student’s t tests for quantitative variables and chiTwo hundred and sixty six patients were eligible to participate to this study, and 162 agreed to take part (61%). Of these, 96 (59%) returned to our centre for a second evaluation and the remaining 66 answered the questionnaire by mail or phone. The remaining 104 patients were either lost at follow-up , dead (n = 1) or declined the study . These 104 patients did not differ from the 162 studied patients in term of clinical or hormonal presentation, except for the presence of autoimmunity markers at first evaluation .The first evaluation was performed 2.1±0.3 [0–3] years after POI diagnosis. The mean follow-up period was 7.4±3.2 [5.6–9.5] years. At baseline, the mean age at the time of the diagnosis for these 162 POI patients was 27.4±7.9 [20.0–33.7] years, the mean age at the first evaluation was 29.5±7.8 [23.2–36.0] years and the mean age at second evaluation was 37.3 ± 8.0 [30.7–44.0] years.Among the 162 POI patients, 48 (30%) were actively followed up in our department; 64 (40%) were followed-up by their gynaecologist, 6 (4%) by an endocrinologist and 34 (20%) by their general practitioner. Absence of any medical follow-up was reported by 10 patients (6%).At B2 evaluation, only 100 patients (61.7%) were under HRT. Among them, 3 used combined oral contraceptives, 50 oral estradiol associated with progestin and 37 transdermal estradiol associated with progestin. In the remaining 10 patients, the type of HRT was not informed.During the follow up period, 69 patients (42.6%) have stopped their HRT at least one year outside of pregnancy. Of these, 10 had a contraindication for the use of estrogens: 2 had a personal history of breast cancer at 47 and 39 years , occurring 9 and 3 years respectively after POI diagnosis; 5 for cardiovascular disease and 3 for thromboembolic disease. Fourteen women had never received hormone replacement therapy since diagnosis. The main reason for discontinuation of HRT was the reporting by these women of an absence of subjective benefice, i.e. quality of life or fertility improvements (n = 32.6%). Other reasons were the presence of diverse side effects , the fear of breast cancer  and weariness . Depending on the practitioner providing monitoring of the POI, HRT was stopped in 10 patients (90%) in the absence of medical follow-up, in 14 patients followed in our department (30%), including 4 with a contraindication, and in 18 patients followed by their general practitioner (53%) Finally, treatment was also stopped in 24 women followed up by their gynaecologist (39%) and 3 (43%) patients followed by an endocrinologist. The comparison between women who stopped their HRT for more or less than one year is represented in 2 at vertebral level and at 32 ±720 mg/cm2 at femoral level. Thirty-one women (34%) had BMD impairment during follow up: 28 patients with initially normal BMD had progressed to osteopenia, none to osteoporosis and 3 patients with initial osteopenia had progressed to osteoporosis. Conversely, seven patients (8%) had BMD improvement during follow-up: 2 with osteopenia had normal BMD and 5 patients with osteoporosis had osteopenia. Among the 92 patients, 55 (60%) were on HRT at B2. Forty-two (46%) of these had stopped their HRT for over a year. Vitamin D status was determined in 89 patients and deficiency (<30 ng/ml) was diagnosed in 69 patients (77.5%). PTH levels were normal in all patients except 5 which present mild secondary hyperparathyroidism due to Vitamin D deficiency. Among them, 4 had normal BMD and one osteopenia. No patients had TSH levels above 10 mUI/L, and 5 between 5 to 10 mUI/L and none had hyperthyroidism history. No fractures were reported.Ninety-two patients had bone mineral density (BMD) determination at initial evaluation and at B2. Clinical characteristics of these women are reported in 2versus -13 mg/cm2 (p = 0.009) at femoral level. In vertebral level, we found a non-significant loss of BMD in women who had stopped their HRT for over a year compared to women who did not: -50 mg/cm2versus -34 mg/cm2 (p = 0.60).In univariate analysis, we found a significant loss of BMD in women who had stopped their HRT for over a year compared to women who did not: -57 mg/cm2 versus -52 mg/cm2 (p = 0.022). In vertebral level, we also found this non-significant trend -37 mg/cm2 versus -45 mg/cm2 (p = 0.80) without any significant variable.In multivariate analysis, after adjustment by stepwise model selection on age (p = 0.05), BMI (p = 0.48), smoking use (p = 0.22) and vitamin D deficiency (p = 0.69), and duration of POI (p = 0.003); discontinuation of HRT over one year was always associated with significant loss of femoral BMD: -17 mg/cm2 at femoral level to -41 mg/cm2 at vertebral level, whereas BMD gain per year of HRT was +23 mg/cm2 at femoral level to -19 mg/cm2 at vertebral level.There was also the reduction of BMD per year of HRT discontinuation from -33 mg/cmVery few studies focus on the following up women with primary POI or in the impact of HRT in these women. The current knowledge on POI comes from the greater part of observational studies integrating women with Turner syndrome ,15. ThisAn important finding of our study was the large number of patients stopping HRT and specialist care. This was attributed mostly to lack of interest or fear of breast cancer. Therefore, information concerning the absence of evidence that HRT increase breast cancer risk to a level greater than that found in normally menstruating women  have to A very early menopause has a potentially devastating effect on long-term bone health ,11,23,24The main limitation of our study is that we did not evaluate the whole cohort of POI patients, so there is a selective participation to our study. However, no differences concerning clinical and hormonal characteristics were found between the POI patients with or without follow-up. Our conclusions came from the largest published POI cohort analysis but have to be confirmed on another large and homogenous POI cohort. There is also a bias with the retrospective collection of data, based on self-reporting. Finally it is an observational study, without a control population. Nevertheless, the key point of our study is the importance of the cohort.In conclusion, our study is the first follow-up analysis of a large cohort of patients with POI. Achieving improved care by physicians should then be expected to improve long-term outcomes for these patients, and precise information regarding HRT should be given, since compliance with this treatment has a direct impact on BMD. Prospective studies are needed to better describe the long-term impact of HRT in these patients, especially on prevention of osteoporotic fracture and on cardiovascular health. Finally, this finding highlights the need to encourage and not just assume that patients will take their HRT. We therefore have to promote specific therapeutic education for these patients, but also the healthcare professionals on this rare disease.


Liquidambar formosana) is a relatively fast-growing ecological pioneer species. It is widely used for multiple purposes. To assess the genetic diversity and genetic differentiation of the species, genic SSR markers were mined from transcriptome data for subsequent analysis of the genetic diversity and population structure of natural populations. A total of 10645 potential genic SSR loci were identified in 80482 unigenes. The average frequency was one SSR per 5.12 kb, and the dinucleotide unit was the most abundant motif. A total of 67 alleles were found, with a mean of 6.091 alleles per locus and a mean polymorphism information content of 0.390. Moreover, the species exhibited a relatively moderate level of genetic diversity (He = 0.399), with the highest was found in population XY (He = 0.469). At the regional level, the southwestern region displayed the highest genetic diversity (He = 0.435) and the largest number of private alleles (n = 5), which indicated that the Southwestern region may be the diversity hot spot of L. formosana. The AMOVA results showed that variation within populations (94.02%) was significantly higher than among populations (5.98%), which was in agreement with the coefficient of genetic differentiation (Fst = 0.076). According to the UPGMA analysis and principal coordinate analysis and confirmed by the assignment test, 25 populations could be divided into three groups, and there were different degrees of introgression among populations. No correlation was found between genetic distance and geographic distance (P > 0.05). These results provided further evidence that geographic isolation was not the primary factor leading to the moderate genetic differentiation of L. formosana. As most of the genetic diversity of L. formosana exists among individuals within a population, individual plant selection would be an effective way to use natural variation in genetic improvement programs. This would be helpful to not only protect the genetic resources but also attain effective management and exploit genetic resources.Chinese sweetgum ( Liquidambar formosana Hance) belongs to the genus Liquidambar of family Altingiaceae  database. A short read archive under accession numbers PCR amplifications were performed in 25 μL reaction volumes as follows: 12.5 μL of 2 × Taq MasterMix , approximately 50 ng of DNA, 5 pmol reverse primer and 5 pmol forward primer with the 5′ end labeled with fluorescent dyes  and sterile double-distilled water added to 25 μL. The amplifications were performed with a touchdown profile, with the first denaturation at 94°C for 5 min, followed by 10 cycles of denaturation for 30 s at 94°C, annealing for 30 s at 63°C and then extension for 45 s at 72°C, with a 1°C decrease in the annealing temperature each cycle; the following 20 cycles included denaturation at 94°C for 30 s, annealing at 55°C for 30 s, and extension at 72°C for 45 s, with a final extension at 72°C for 7 min. All the PCR reactions were performed in the same thermal cycler . The PCR products were separated by a ABI 3730XL capillary electrophoresis analyzer  with a GeneScan-500LIZ size standard. Fragments were genotyped for their presence/absence at each locus, and the allele sizes were scored using GeneMaker 2.2.0 software  and visually checked twice to reduce genotyping errors. The genotyping error was computed by the blind replication of approximately 13.5% of the amplifications . The repeated genotypes were compared to the previous ones, and the number of allelic differences was counted.Na), the effective number of alleles (Ne), Shannon's information index (I), expected heterozygosity (He), observed heterozygosity (Ho), and Wright's F statistics parameters  were computed using POPGENE32 software  and geographic distance (km) to analyze the isolation by distance among populations. The significance was evaluated by performing 10,000 randomization  carried a single SSR locus and 1454 (16.06%) contained more SSR loci.A total of 80482 unigenes comprising approximately 56.25 Mb in L. formosana transcriptome data were calculated (Table n = 6 (23.42%), containing the most dinucleotide repeats.The frequencies of different types of genic SSR motifs in ed Table . ApproxiOf the 72 genic SSR primer pairs designed, 45 pairs successfully produced the expected product by amplification, with a success rate of 62.5%, but only 14 primer pairs showed abundant polymorphisms. The characteristics of the polymorphism primers were presented in Table L. formosana.MICRO-CHECKER analysis showed that several loci exhibited null alleles in some populations. At LF 15, LF 26, LF 72, null alleles were detected in the 17, 20, and 19 populations, respectively Table . So, theNa) per locus ranged from 3 (LF 40) to 10 (LF 69), with a mean of 6.0909, whereas the effective number of alleles (Ne) per locus varied from 1.2709 (LF 40) to 2.8047 (LF 17), with an average value of 1.9266. The Shannon's Information Index (I) had an average of 0.8178 and ranged from 0.3823 (LF 40) to 1.2657 (LF 19). Observed heterozygosity (Ho) and expected heterozygosity (He) varied from 0.2012 (LF 40) to 0.6411 (LF 17), and 0.2133 (LF 40) to 0.6439 (LF 17), with an average of 0.4090 and 0.4322, respectively. He was higher than Ho at 10 loci, with the exception being LF 25, in accordance with the mean inbreeding coefficient at the total population (Fit = 0.056). The value of the polymorphism information content (PIC) ranged from 0.192 (LF 40) to 0.580 (LF 17 and LF 19) with a mean of 0.3904 (Table PIC showed that highly polymorphic loci (PIC > 0.5) comprised 36.4% of all loci, whereas moderately polymorphic (0.25 < PIC < 0.5), and lowly polymorphic (PIC < 0.25) loci occupied 36.4% and 27.2%, respectively.A total of 67 alleles were generated by the 11 SSR loci in all samples. The number of alleles , whereas the lowest was detected in population BWL (He = 0.302). In population SZHN, He (0.341) was higher than Ho (0.287), which implied that there was a deficit of heterozygosity in the population, possibly due to the existence of inbreeding. We assessed the level of genetic variation among four different regions, and these results showed that the highest genetic diversity  and the largest number of private alleles (n = 5) was found in the Southwestern populations, whereas the lowest genetic diversity  and a relatively low number of private alleles (n = 1) were discovered in the Central populations.The genetic diversity at the population and region level is presented in Table Fis) per locus varied from −0.1915 (LF 25) to 0.0476 (LF 69) with a mean of −0.0213, and these results indicated an excess of heterozygosity. However, a deficiency of heterozygosity was discovered at six loci: LF 3, LF 29, LF 32, LF 40, LF 49, and LF 69. Furthermore, the inbreeding coefficient at total populations (Fit) ranged from −0.1354 (LF 25) to 0.1818 (LF 69) with an average of 0.056. Moreover, the genetic differentiation (Fst) ranged from 0.0461 (LF 40) to 0.1409 (LF 69) with a mean of 0.0757, which indicated moderate differentiation among populations (Table The inbreeding coefficient within populations (K = 16.13) was at the value K = 3 . These results provided further evidence that geographic isolation was not the primary factor leading to moderate genetic differentiation of L. formosana.The Mantel test revealed that no correlation was found between genetic distance and geographic distance in L. formosana was one SSR locus per 5.28 kb, which is lower than that of Larix gmelinii (one SSR locus per 2.87 kb)   may be helpful for targeting genic SSRs of plant materials at different taxonomic levels.The mean frequency of SSR loci detected in He = 0.399) detected in our study was only relatively moderate. The genetic diversity was lower than the average value (He = 0.650) of outcrossing plants using SSR markers  and the National Forest Genetic Resource Platform (2005DKA21003).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In French Guiana, a French overseas territory in South America, 6 to 10 thousands undocumented persons work illegally in gold mining sites in the Amazonian forest. Precarious life conditions lead to poor health but few data exist on the health status of illegal gold miners in French Guiana. The objective of this article was to describe the sociodemographic and health status of this vulnerable population.A prospective cross-sectional survey was conducted in 2015 on gold mine supply sites at the border between French Guiana and Suriname. Health status was assessed through medical examination, past medical history, haemoglobin concentration, and HIV and malaria testing. A questionnaire was used to collect data about the migration itinerary and life conditions on mining sites.Among the 421 adults included in the study, 93.8% (395/421) were Brazilian, mainly from Maranhão , the poorest Brazilian state. The sex ratio was 2.4. Overall, 48% of persons never went to school or beyond the primary level. The median time spent in gold mining was quite long (10 years), with a high turn-over. One third of the surveyed population  had high blood pressure, and only two had a medical follow-up. Most persons had experienced malaria . They declared frequent arboviroses and digestive disorders. Active leishmaniasis was observed in 8.3% of gold miners. Among women, 28.5% were anemic. Concerning HIV, 36.6% (154/421) of persons, mainly men, never got tested before and 6 were tested positive, which represented an HIV prevalence of 1.43% (95%CI =0.29–2.5).These findings support the hypothesis that mining in remote areas is linked to several specific illnesses. Theoretically, gold miners would be presumed to start their economical migration to French Guiana as a healthy group. However, their strenuous working and living conditions there lead to poor health caused by infectious and non infectious diseases. This description of their health status is precious for health policy planners in French Guiana given the importance of controlling communicable disease, and the severity and range of specific illnesses acquired by this neglected population.NCT02903706.Clinical trial registration PRS N° Retrospectively registered 09/13/2016. Other persons were born in Suriname , in France , in Guyana , in Venezuela  and in Peru . In Brazil, states of birth were mainly Maranhão , Para  and Amapa  . Only 13 workers (3.1%) had French social security, one of which was born in France, 3 in Suriname, 9 in Brazil; 7 were women, and 2 were pregnant.Half of illegal gold miners (48%) never went to school or only had a primary school level. Women had significantly higher education than men: 72.6% had a secondary school level versus 43.4% of men . The surveyed persons currently worked in 68 different mining sites, which were grouped in 10 zones according to their proximity and river basin. There was no difference of sex ratio or duration of gold mining activity between those zones, but people were younger in Sophia, Papaïchton and Beiman areas than in others mining areas (p = 0.002). Place of birth (country and state in Brazil) also differed between zones (p < 0.001). Twenty-seven persons were included directly on mining sites in French Guiana. For people included at resting sites, the distance between the resting site and the mining site was one day or more for 63.7% (251/394). Modes of transport were boat (99.5%), foot (37.8%), quad (12.8%) and car (1.7%). During the last three years, gold miners had worked in a median number of three different mining sites [IQR = 2–4], ranging from 1 to 25 sites. The majority worked only in FG . Other persons worked also in Suriname (29.2%), in Brazil (3.6%), in Guyana (2.8%) or in Venezuela (1.2%). Fifteen (3.6%) worked in three or more countries. They had been on the current mining site for a median of six months [IQR = 3–18 months]. The gold extraction was alluvial for 48.5% (204/421) of gold miners, wells for 8.1% (34/421) and both for 39.2% (165/421). Other extraction modes were “moinho” (rock crushing) (9/421) or “pioupiou”  (3/421). Six did not answer this question.Type of work in mining sites differed statistically by sex and 25 persons declared having two jobs. Women were mainly cookers or housewifes (53.2%) or travelling sellers (40.3%); 9.3% declared sex work activity. Among men, 68% were gold miners, 12.1% travelling sellers, 7.7% transporters, 5.7% machine operators , rest (37%), medical care (25.6%) or family visit (16.4%).During the past year, 68.2% (287/421) of people declared having moved in a city of the Guiana Shield, a median number of three times [IQR = 1–6]. Most of them went to Paramaribo (49.4%), then Saint Laurent du Maroni (20.1%), Belem (19%), Oiapoque 13%), Macapa (9.5%), Cayenne (8%) and Kourou (2.6%) , dengue or chikungunya (135), digestive disorders (76), and musculoskeletal disorders (67) Fig. .Fig. 4Map = 0.001): 93 (22.1%) at grade 1, 47 (11.2%) at grade 2, and 16 (3.8%) at grade 3. Among the ten persons reporting a past history of HBP, two had a medical follow up at the health center of Maripasoula and 2 had erratic treatment use. Concerning cardiac disorders, 7 (1.7%) persons declared having had a myocardial infarction and 14 (3.3%) suffering from cardiac rhythm disorder. Cardiac auscultation found two heart murmurs and four rhythm disorders but not in any of the gold miners with cardiac past history. Two had edema of the lower limbs.More than a third  of gold miners suffered from high blood pressure (HBP), mainly men , none with hemoglobin below 8 g/dl. Anemia was not related with pregnancy among women. Twenty three persons declared currently having diarrhea . Thirty five persons (8.3%) had active leishmaniasis. Most of them  had only one lesion, but twelve (34.3%) had several lesions, up to 5. During the past year, 57 persons (13.5%) declared having had an anti-leishmanial treatment. Among them, 18 (31.6%) still had active leishmaniasis at inclusion time. Almost all (89.3%) declared a past malaria history, of which 66.2% declared more than 7 prior malaria attacks. Plasmodium spp. prevalence was very high, 22.3% (CI95% = 18.3–26.3) of the study population [Plasmodium spp. positive. Concerning HIV, 36.6% (154/421) had never been tested for HIV. This proportion differed between sexes: 17.7% of women versus 44.4% of men (p < 0.001). Six samples were found positive with the ELISA assay which is a prevalence of 1.43% (95%CI =0.29–2.56). They all presented Western blot profiles of chronic HIV infection and were positive only for HIV-1 with Immunocomb®. One was already known to be HIV positive and received care atthe health center of Maripasoula. The 6 HIV positive individuals were aged between 29 to 47 years with a sex ratio of 2:1. The two women declared to be a housewife and cooks, and did not mention sex work. The men were: a shop employee [Twenty two percent of included persons had anemia 95%CI =18–25.9), mainly women . Often illiterate, the motive of migration of these persons for gold mining is thus mainly economic as shown in other qualitative reports among miners –28. The garimpeiros worked day and night, testifying of their exhausting work.The majority of the surveyed population reported having only worked in French Guiana during the last three years. Actually, in Brazil, illegal gold mining is severely repressed and in Suriname, corruption and concurrence with local persons make it difficult to work for one’s own account , 25. SinPlasmodium spp. prevalence was very high [Aedes aegypti, the main vector in French Guiana, usually lays in clean still water in urban areas.In fact, A. aegypti larvae were found in Bromeliad plants in the rainforest, suggesting that those viral outbreaks can emerge at mining sites [A. aegypti larvae were found in flooded disused mine shafts and wells [Malaria was the first health problem cited by interviewed people. Although it might have been influenced by the main topic of the study, almost all declared past malaria history and ery high , 30. Morng sites . In Austnd wells , 32. Othnd wells –35. MayaDigestive disorders also appeared as an important health problem, linked to the lack of latrines and drinking water . High prPrevalence of anemia among women in this study was higher than reported by WHO among women of reproductive age in the Americas: 28.5% (95% CI = 20.4–36.5) versus 16.8% (95% CI = 12.6–23.8) . This caThe prevalence of HBP was higher in this study than in Brazil(37.1% versus 22.8%) , while tL.guyanensis or L.brasiliensis [Illegal gold miners are also exposed to cutaneous disorders such as leishmaniasis due to iliensis . Transmiiliensis . Thus deiliensis , the higGold mines are potential hotspots for HIV transmission. Sex work seems to be very frequent in gold mining and HIV prevalence has been shown to be higher in sex worker populations –53. GiveGarimpeiros are also exposed to fauna poisoning . Given the hard life conditions, alcohol and drugs are often used on gold mining sites [Leprosy cases diagnosed in FG mainly concern gold miners originating from Brazil, the country with the second highest number of leprosy cases in the world , 59. Batng sites . The useng sites , 18, 60.ng sites , 61.Migration could hamper access to health care because of the poverty related to their status, the lack of knowledge about health care or geographical isolation. In a recent study, Médecins Sans Frontières (Doctors Without Borders) reported that death and default rates of tuberculosis treatment for migrant workers were higher than the rates for refugees . This stThese findings support that mining in remote area is strongly related to several specific illness. Theoretically, given the strenuous working conditions, gold miners would be presumed to start their economical migration to French Guiana as a healthy group, which is called the “salmon bias” , 65. HowOther studies in French Guiana, as elsewhere in the world, suggest that undocumented immigrants are most vulnerable with regards to health , 69. EveThe hostile living conditions at mining sites erodes the miners’ health and leads to a broad range of serious non communicable and communicable diseases that may spread beyond mining sites and beyond borders. Improving the knowledge on their specific burden of disease is crucial for health policy planners for disease control. An effective response will benefit from multi-sectoral approaches for dealing with specific disease-related risks, behaviors and environmental Amazonian factors. Consequences of inaction could have repercussion far beyond French Guiana.


Pneumococcal carriage is the precursor for development of pneumococcal disease, and is also responsible for transmission of the organism from person-to-person. In Africa, little is known about the pneumococcus in relation to people with HIV infection. The aim of the study was to investigate the epidemiology of pneumococcal carriage among HIV infected children visiting a tertiary hospital in Ghana, including the carriage prevalence, risk factors and serotype distribution.Streptococcus pneumoniae and the isolates were serotyped by latex agglutination. The data of the study was analysed using STATA 11 .This was a cross sectional study carried out from February to May, 2015 at the HIV Paediatric Clinic of the Korle-Bu Teaching Hospital in Accra, Ghana. One hundred and eighteen HIV infected children were recruited and nasopharyngeal (NP) swabs were collected from them. Epidemiological data on demographic, household and clinical features of the study participants were also collected. The NP specimens were cultured for p = 0.034). The most prevalent pneumococcal serotype among the study participants was serotype 19F (24.4%), followed by 16F (22%). Serotype coverage of the 13-valent Pneumococcal Conjugate Vaccine in this study was 41.5%. Multiple carriage of pneumococcal serotypes among the positive carriage cases was 34.3%.Prevalence of pneumococcal carriage among the HIV infected children was 27.1% (95% CI: 19.1 to 35.1) and the only factor significantly associated with pneumococcal carriage was the presence of respiratory symptoms (OR, 2.63; CI, 1.06-6.53; Pneumococcal carriage occurred in more than a quarter of the study population and was characterized by predominance of non-vaccine serotypes as well as a high prevalence of multiple carriage. Presence of respiratory symptoms appears to be a major determinant of pneumococcal carriage among the study population. Streptococcus pneumoniae also referred to as pneumococcus, is part of the normal bacterial flora of the upper respiratory tract of humans. Carriage of the organism is affected by a wide range of factors such as age, acute respiratory tract infection and immunosuppression [pression , 2. An ipression , 4. Clinpression . HIV infpression .http://www.gavi.org/, www.view-hub.org). Two types of pneumococcal conjugate vaccines (PCVs) are currently in use and they include the 10-valent vaccine which comprises pneumococcal serotypes 4, 6B, 9V, 14, 18C, 19 F, 23 F, 1, 5, 7F and the 13-valent vaccine which has three additional serotypes of 3, 6A, 19A [The vast burden of the pneumococcus underlies the importance of control through vaccination, and recently, pneumococcal conjugate vaccines are being introduced into the childhood vaccination programmes of many developing countries  located in Accra, the capital city of Ghana. The population of Ghana is about 25 million people and the HIV prevalence is 1.6% , 14. KorUsing a 95% confidence level, 81% estimated pneumococcal carriage prevalence reported previously , and 5% Nasopharyngeal specimens were collected from the study subjects according to the World Health Organization guidelines by a qualified pediatrician . The subUsing questionnaires, data were collected from the study participants on risk factors of pneumococcal carriage. The questionnaire covered three areas including demographic features  clinical features  and household characteristics .2 [Briefly, the nasopharyngeal specimens were inoculated onto 5% blood agar plates, followed by an overnight incubation at 37 °C in 5% CO2 . Suspect2 , 21–23. 2  The pneup-values, odds ratio and confidence intervals; p < 0.05 was regarded as significant. Serotype distribution was evaluated and impact of pneumococcal vaccination among the HIV children was estimated by the theoretical coverage of PCV 10, PCV 13 and PPV 23.Data was analysed using STATA 11 . Descriptive analyses including computation of arithmetic means, frequencies and percentages were done on the study variables. Univariate associations were performed between pneumococcal carriage and demographic, clinical and household features: analysis of variance was used for numeric variables, whereas chi-square test was used for categorical variables. Since only one variable emerged significant in the univariate analyses, multiple logistic regression was not carried out. Significance of variables was assessed by Demographic and household features of the hundred and eighteen 118) HIV positive children recruited in the study are reported in Table 18 HIV po3 and 82.2% of them were on antiretroviral drugs. Only 11% had received the pneumococcal vaccine (PCV13). A proportion of 56.8% had respiratory symptoms and the most common symptom was cough (38.5%) followed by runny nose (25.6%). Otitis media occurred in 23.9% of the study participants while 4.3% were asthmatic.As shown in Table Overall 32 of the 118 study children carried pneumococcus, which translates to a carriage prevalence of 27.1% (95% CI: 19.1 to 35.1); carriage among the different age groups of < 5 years, 5–9 years and > 9–15 years were, 28.6% (95% CI: 20.5 to 36.8%), 51.9% (95% CI: 42.9 to 60.9%), 17.1% (95% CI: 10.3 to 23.9%) respectively.p = 0.034). Previous receipt of pneumococcal vaccination or being on antiretroviral medication did not affect pneumococcal carriage significantly  and 16F (22%) ; all the cases of multiple serotype carriage involved two serotypes with the exception of one case where three serotypes were carried. In the multiple carriage events, 63.6% (7/11) co-carried at least one vaccine serotype and a non-vaccine serotype, 27.2% (3/11) co-carried at least one vaccine serotype and a non-vaccine serotype, and 9.1% (1/11) carried vaccine serotypes only.et al. [In this study, the epidemiology of pneumococcal carriage among HIV positive children less than 15 years was investigated among outpatients at the Korle-Bu Teaching Hospital in Ghana. This study is to our knowledge the first report on pneumococcal carriage among HIV infected people in Ghana, and one of the few in sub-Saharan Africa. It is important to note that data from this study is post-vaccination data as the pneumococcal vaccine was introduced in Ghana in 2012. We observed an overall pneumococcal carriage prevalence of 27.1% whereas previous pre-vaccination data in Ghana reported carriage prevalence of 27–51% among children < 6 years , 25. By et al.  reportedThe association of respiratory symptoms with pneumococcal carriage in this study has been previously reported for both HIV infected and healthy children , 19, andOne of the predominant serotypes in the current study (19F) was also reported to be predominant among healthy children in Ghana during carriage surveys done before introduction of the pneumococcal conjugate vaccine in the country , 12. HowPrevalence of carriage of multiple serotypes in the current study (34.3%) seems very high compared to the 10% prevalence reported among healthy children in Ghana by Dayie et al. . A studyThis study presents to our knowledge the first post-vaccination data on pneumococcal carriage in Ghana. More than a quarter of the HIV infected children carried pneumococcus and the presence of respiratory symptoms appears to be an important determinant of pneumococcal carriage among the study population. There is a predominance of non-vaccine serotypes of the pneumococcus in carriage among the HIV infected children, particularly serotype 16F. Further studies are needed in the general population in Ghana to throw light on the evolution of pneumococcal serotypes following introduction of PCV13.


Metformin is contraindicated in diabetic patients with declining renal function. This study examined the glycaemic control in diabetic patients with chronic kidney disease when metformin was discontinued. This was a retrospective study. We screened 2032 diabetic patients who attended the Diabetes Clinic at a tertiary hospital between 1 September 2014 and 30 September 2015. We analyzed the data on 69 patients whom metformin was discontinued due to declining renal function and had a complete 6-month follow-up. There was no significant difference in the HbA1c and body weight at 6-month follow-up compared to baseline after metformin discontinuation. The eGFR was significantly lower at 6-month follow-up compared to baseline. Upon metformin discontinuation, the majority of patients had their diabetes medication uptitrated (in particular insulin or sulphonylurea). Patients with an improved glycaemia at 6-month follow-up had further declined in eGFR compared to patients with worsened glycaemia. 17% of the study patients experienced hypoglycaemia. Upon metformin discontinuation, glycaemic control could be optimised with uptitration but should be balanced against the risk of hypoglycaemia. Further improvement in the glycaemic control might indicate further deterioration in the renal function. The paired A total of 2032 patients who attended the Diabetes Clinic, National University Hospital, Singapore between 1 September 2014 to 30 September 2015 were screened . There wμmol/L (56.9 μmol/L) with the corresponding mean eGFR was 29.7 ml/min/1.73 m2 (13.0 ml/min/1.73 m2) at metformin discontinuation. Twenty-eight patients (40%) had metformin discontinued even when their baseline eGFR was between 30 and 60 ml/min/1.73 m2. Body weight did not change significantly throughout the 6-month study period (p = 0.148). However, the mean eGFR declined significantly from 29.7 ml/min/1.73 m2 (13.7 ml/min/1.73 m2) to 26.4 ml/min/1.73 m2 (11.2 ml/min/1.73 m2) (p = 0.049). The mean HbA1c was 8.8% (2.3%) at baseline, 9.2% (2.2%) at three months, and 9.0% (2.2%) at 6-month follow-up (p = 0.262).Baseline patients' characteristics are shown in n = 25, HbA1c decreased >0.5% at 6-month follow-up from baseline) and worsened glycaemic control  (We identified two groups that had improved (aseline) . There wp < 0.001) at 3 months of follow-up after metformin discontinuation. In the improved glycaemia group, there were significant differences in the decrease in the proportion of patients with uptitration in medication (p < 0.001) and in the increase in the proportion of patients with downtitration of medication (p = 0.046) at 3 months of follow-up compared to baseline.Figures Twelve out of the 69 patients  reported hypoglycaemic episodes. All patients were on insulin therapy.2 and to decrease the metformin dose in mild to moderate renal impairment (eGFR 30–60 ml/min/1.73 m2). We noted that 40% of the study subjects had metformin prematurely withdrawn when eGFR was between 30 and 60 ml/min/1.73 m2, and therefore they were potentially deprived of the overall reduction in morbidity and mortality, low hypoglycaemia risk, and cardiovascular benefits of metformin [We reported the changes in the glycaemia level and glycaemia management among diabetic patients in whom metformin was discontinued due to declining renal function. It is recommended that metformin should be discontinued once eGFR falls below 30 ml/min/1.73 metformin , 6.While there is a clear recommendation on metformin discontinuation when renal function declines, there is no recommendation on how to manage the glycaemia upon metformin discontinuation. We found that there was no significant change in the glycaemic control at 6-month follow-up after metformin discontinuation. Majority of the patients had their medication uptitrated or had an additional antidiabetic agent when metformin was discontinued.Although we did not find a significant change in the glycaemic control 6 months after metformin discontinuation, we observed that the glycaemic control deteriorated in the first 3 months after metformin discontinuation. Interestingly, we found that there were two groups of patients that experienced worsening or improvement in the glycaemic control at 6-month follow-up. The worsening of glycaemia was expected after metformin discontinuation, but optimisation of antidiabetic agents at metformin discontinuation and 3 months of follow-up did not stem off the worsening of glycaemia at 6-month follow-up in the group with worsened glycaemia. Similar treatment optimisation was observed in the group with improved glycaemia, and in fact, the treatment regimen was downtitrated at 3-month follow-up. A further decline in the renal function in the improved glycaemia group likely contributes to the improvement in glycaemia and explains the downtitration of treatment regimen at 3-month follow-up.Glucose homoeostasis is complex in diabetic nephropathy. Insulin resistance plays a key role in the worsening of glycaemic control in patients with a decline renal function –9. The iImportantly, the optimisation of antidiabetic treatment must take into consideration the risk of hypoglycaemia. About 20% of our patients experienced hypoglycaemia within 6 months of optimisation of antidiabetic treatment. Aside from poor renal function, other risk factors for hypoglycaemia were seen in these patients such as old age, long duration of diabetes, high glycosylated haemoglobin, and the use of insulin. In the group with improved glycaemia, there was less treatment intensification at 3 months of follow-up, and this might have mitigated the hypoglycaemia risk in this group.2). None of our patients were on PPAR-agonist or GLP-1 agonists. Thus, our interpretation of the data is limited to increasing the dose or addition of insulin, sulphonylurea, or DPP-IV inhibitor upon metformin discontinuation.This study has several limitations. It is a retrospective study. We could not validate compliance to medications and dietary restriction. Our study has a small sample size, and this is due to our strict inclusion and exclusion criteria. We did not take into consideration patients whom metformin dose was reduced given the early decline in renal function (eGFR between 30 and 60 ml/minute/1.73 mIn conclusion, upitration of existing insulin or sulphonylurea or addition of DPP-IV inhibitor might help to mitigate deterioration in glycaemic control upon metformin discontinuation due to declining renal function. In patients with continuous improvement in glycaemic control, it is important to follow the renal function closely, as this may be a harbinger of a rapid decline in renal function toward end-stage kidney disease. Also, the optimisation of diabetes treatment should take into consideration the risk of hypoglycaemia in patients with a declining renal function.