Tuberculosis kills five lakh patients every year in India, commonest being pulmonary tuberculosis and is often associated with effusion. Delay in diagnosis and treatment results in poor prognosis. Several studies have suggested the role of adenosine deaminase (ADA) in the diagnosis of tuberculous pleural effusions, but false-positive results from lymphocytic effusions have also been reported. The purpose of this study is to find out the role of ADA levels in differentiation of tuberculous and non-tuberculous exudative pleural effusions of different etiologies.Ninety-six lymphocytic pleural fluid samples were consecutively selected and divided into two groups: tuberculous (n = 56) and non-tuberculous (n = 40), depending upon the etiology . ADA was estimated in pleural fluid in all the cases.In all 56 samples, ADA level of tuberculous group was above diagnostic cut-off (40 U/L), while only one sample was above cut-off in non-tuberculous group (2.5%). The negative predictive value of ADA for the diagnosis of non-tuberculous etiology was 97.5% (39 of 40) lymphocytic pleural effusion patients.In this study, ADA levels in nontuberculous exudative pleural effusions rarely exceeded the cut-off; set for tuberculous disease. The pleural fluid ADA levels were significantly higher in tuberculous exudative pleural effusions when compared with non-tuberculous exudative pleural effusions.Adenosine deaminase; Tuberculous effusion; Pleural fluid; Exudative pleural effusions Five lakh patients of tuberculosis die every year in India , commoneSimilar difficulties are encountered in cases of tuberculous pleuritis (TP). TP with effusion as a complication of primary pulmonary tuberculosis has been reported to occur in 2 to 38% of children with pulmonary disease, but it is more likely to occur in adolescents and adults . The pleThe classification of pleural effusion into exudative and transudative to support the clinical diagnosis has been well established. There are several causes of exudative pleural effusion including tuberculosis, neoplasms (primary or secondary), pyogenic bacterial infections, fungal infection, sarcoidosis, collagen vascular disease, transplant patients with graft rejection, trauma, and pulmonary embolism. Microscopy of fluid shows neutrophillic predominance in bacterial infectious etiology, while in others there is lymphocytic predominance. Presentation of pulmonary embolism can be obscure either as a transudative or an exudative pleural collection.Usefulness of adenosine deaminase (ADA) estimation in pleural fluid has been shown as a reliable chemical biomarker specially when there is suspicion of tuberculosis in endemic areas. Sometimes the increase is marked in early stages of the disease and in some other conditions with neutrophillic effusions like in parapneumonic and empyema . ResearcThe purpose of this study is to find out the role of ADA estimation in differentiation of tuberculous and non-tuberculous exudative pleural effusions.The project was approved by institutional ethical committee. Patients with pleural effusion admitted in the wards of Tuberculosis and chest diseases department from January 08 to November 09 at the Subharti Medical College, Meerut, India were included in the present study. After the routine procedure of informed consent, history taking and examination, routine investigations were done in all the patients.Presence of first or more than one of the following criteria was adopted to label a case as tuberculous: (1) bacteriological confirmation of presence of Mycobacterium tuberculosis ; (2) histopathology finding of caseating granulomas; (3) radiological findings consistent with TB; (4) clinical presentation consistent with TB with exclusion of other clinical considerations; (5) definite clinical and radiological improvement in two months of administration of exclusive anti-tubercular treatment; (6) history of contact of current disease and positive reaction (> 20 mm induration) to the 5 tuberculin unit (TU) purified protein derivative (PPD).Pleural tap was done in all the cases and fluid tested for pH, glucose, proteins, LDH, total ADA, microscopy, cytology and microbial testing . Pleural biopsy was done in selected cases of tuberculosis and malignancy.All the cases had exudative effusion as per Lights criteria  .Effusion was called as malignant when pleural fluid cytology or pleural biopsy showed evidence of malignancy or if the patient had proved metastatic malignancy with no other detectable cause of effusion. In infectious disease effusion, patient had a history of fever and pulmonary infiltrate with complete response to antibiotic therapy; pulmonary embolism effusion patients presented with typical dyspnoea of sudden onset, leg pains with its signs and symptoms; collagen vascular disease effusion patients had a history of fever and dyspnoea with evidence of eosinophilia and arrhythmia while sarcoidosis effusion patients had multi organ involvement with presence of non-caseating granuloma.Adenosine deaminase estimation was done by Blake-Berman method  which isResults are expressed as Mean ± SD. The statistical analyses applied included the standard normal variate test, to analyze the difference between tubercular (n = 56) and non-tubercular (n = 40) quantitative variables at 1% level of significance .In our study, 96 samples were thus included between the age group of 12 to 76 years. Male : Female ratio is 3 : 1. Tuberculous group had 56 samples while non-tuberculous group had 40 samples. Non-tuberculous group included different etiologies, namely, malignancy (n = 16), infectious diseases (n = 18), pulmonary embolism (n = 1), collagen vascular diseases (CVD) (n = 3) and sarcoidosis (n = 2) .Out of 56, only 9 cases (16.07%) were confirmed as having tuberculosis by bacteriological confirmation of presence of Mycobacterium tuberculosis.Mean ± SD of pH in tuberculous group was 7.31 ± 0.09, in malignant group it was 7.32 ± 0.07, in infectious disease group it was 7.31 ± 0.08, in pulmonary embolism it was 7.29, in CVD group it was 7.27 ± 0.05 while in sarcoidosis it was 7.32 ± 0.03 .Mean ± SD of glucose in tuberculous group was 46.2 ± 17.6, in malignant group it was 42.2 ± 19.6, in infectious disease group it was 31.4 ± 17.8, in pulmonary embolism it was 40.7, in CVD group it was 51.5 ± 14.6 while in sarcoidosis it was 58.8 ± 18.9 mg % .Mean ± SD of protein in tuberculous group was 4.3 ± 0.9, in malignant group it was 4.2 ± 1.1, in infectious disease group it was 4.1 ± 1.2, in pulmonary embolism it was 3.9, in CVD group it was 4.4 ± 0.7 while in sarcoidosis it was 4.2 ± 0.9 gm % .Mean ± SD of LDH in tuberculous group was 151.6 ± 27.0, in malignant group it was 147.4 ± 18.6, in infectious disease group it was 141.7 ± 23.1, in pulmonary embolism it was 136.0, in CVD group it was 154.6 ± 13.7 while in sarcoidosis it was 148.6 ± 11.6 U/L .In tuberculous group the range of ADA was 115.4 (40.6 - 156.0) and mean ± SD was 67.34 ± 22.85 while collectively in non-tuberculous group it was 33.2 (4.8 - 38.0) and 18.60± 9.12 .Amongst different groups in non-tuberculous disease: in malignant group range of ADA was 26.6 (6.4 - 33.0) and mean ± SD was 9.08 ± 9.96, in infectious disease group its range was 27.2 (4.8 - 32.0) and mean ± SD was 18 ± 7.83, in pulmonary embolism it was 13.58, in CVD group its range was 5 (10.0 - 15.0) and mean ± SD was 12 ± 2.65, in sarcoidosis group its range was 8 (30.0 - 38.0) and mean ± SD was 34 ± 5.66 U/L .Adenosine deaminase level in all 56 samples of tuberculous group was above diagnostic cut-off (40 U/L); while in non-tuberculous group only one sample was above cut-off (2.5%). The negative predictive value of ADA for the diagnosis of non-tuberculous etiology was 97.5% (39 of 40) exudative pleural effusion patients .Adenosine deaminase values were compared between tuberculous and non-tuberculous groups and difference in these values was statistically highly significant. On comparing the ADA values amongst different non-tubercular groups; the difference was not statistically significant .Tuberculous pleurisy (TP) is a result of delayed hypersensitivity reaction to the tubercle bacilli. Exudative pleural effusion is manifested by various diseases. The diagnosis based on pleural tap: AFB staining is positive in only 10 to 25% of the cases, while culture for AFB is positive in less than 25% of the cases . Perez eIn patients with tuberculous exudative pleural effusion, neutrophils predominate in the early stages of the disease, while abundant mononuclear cells is a classical finding later and is believed to be due to the proliferation and differentiation of lymphocytes which release lymphokines, which in turn activate macrophages for an enhanced bactericidal activity , 26. EveSince the conventional diagnostic tools are incapable of pinpointing the cause, so several bio-markers like ADA, interferon (IFN)-γ, a variety of tumor markers and cytokines, and C-reactive protein (CRP) have been proposed as alternative noninvasive means of establishing tuberculous etiology in cases of exudative pleural effusion .Adenosine deaminase estimation in pleural fluid has long been taken as a marker for tuberculous pleurisy. Levels above 40 U/L indicate pleural tuberculosis with sensitivity 81 to 100% and specificity 83 to 100% , while sThe ADA is an enzyme involved in the purine catabolism. It catalyzes the deamination of adenosine to inosine and of deoxyadenosine to deoxyinosine. Adenosine deaminase is involved in the proliferation and differentiation of lymphocytes, specifically the T-lymphocytes. The T-cells release ADA during the process of activation in the presence of live intracellular pathogens. Thus ADA has been looked upon as a marker of cell mediated immune response and specifically T-cell activation. There are several known isoforms of ADA, which arise from different gene loci  out of wDaniil et al, in their study, concluded that the combination of pleural ADA and CRP levels might be sufficient for discriminating between the different groups of exudative pleural effusion . Jadhav We have found the pleural fluid ADA levels to be consistently increased and more than the cut-off (40U/L) in cases of exudative pleural effusions of tuberculous etiology. In cases with non-tubercular exudative pleural effusion the ADA levels were found to be consistently below the cut-off. The negative predictive value of ADA for the diagnosis of non-tuberculous etiology was 97.5%. Therefore, pleural fluid ADA levels can play a very significant role in differentiating cases of exudative pleural effusion into tuberculous and non-tuberculous.On the contrary, Rafael concluded that the ADA assay should be considered as a screening test to guide further diagnostic procedures in cases of exudative pleural effusion . While KThe sensitivity of the ADA as a serological marker for tuberculous exudative pleural effusion depends on the prevalence of the disease in the population. In western countries where the prevalence of tuberculosis is low, the positive predictive value of the test decreases because of the high false positives, but the negative predictive value remains high. Thus ADA can be used for ruling out suspected cases of tuberculosis and can be a very effective screening test.India has a high prevalence of tuberculosis and the sensitivity and specificity of this test will be high in this population. Therefore ADA estimation being a simple, low cost, rapid and non-invasive test, should become an integral part of the diagnostic work up of exudative pleural effusions in suspected cases of tuberculosis.In conclusion, in this study, ADA levels in non-tuberculous exudative pleural effusions rarely exceeded the cut-off; set for tuberculous disease. The pleural fluid ADA levels were significantly higher in tuberculous exudative pleural effusions when compared with non-tuberculous exudative pleural effusions. Adenosine deaminase level of less than 40 U/L practically excludes the tubercular etiology in exudative pleural effusion cases and thus may be useful in differentiating tuberculous etiology from others in exudative pleural effusion.


The newly approved oral anticoagulant dabigatran has no effective antidote. We therefore suspected an overall increase in mortality in patients presenting to the emergency department (ED) with a bleeding complication on dabigatran compared with warfarin or aspirin.post hoc analysis on a database of all patients admitted to a tertiary-care ED with any kind of bleeding or suspicion of one from March 2011 to August 2012 who were taking dabigatran, warfarin, or aspirin. The primary endpoint was long-term survival. Patients were censored at death or at the end of the study period (7 December 2012). We performed a Cox proportional hazard model, controlled for age, to calculate the hazard ratio (HR) for dabigatran versus warfarin and one for warfarin versus aspirin. Statistical significance was set at α = 0.05 and results are presented with 95% CI.We conducted a P = 0.05 after controlling for age. Aspirin had a lower  mortality risk compared with warfarin; HR = 0.75 (95% CI: 0.50 to 1.14), P = 0.18 after controlling for age.In total, 943 patients met the inclusion criteria with a mean follow-up period of 1 year. The mean age was 74.3 years and 50.4% were men. A total of 108 deaths (11.5%) were recorded within the follow-up period; eight (25%) for dabigatran compared with 44 (12.6%) for warfarin and 56 (9.9%) for aspirin. The mortality risk for patients on dabigatran was significantly higher than for patients on warfarin: HR = 2.1 (95% CI: 1.0 to 4.5), n = 32), and further studies are needed to corroborate the results.The results showed higher overall mortality in patients who presented to the ED with a bleeding complication and were taking dabigatran compared with warfarin or aspirin. Physicians should be aware of the potential higher mortality with dabigatran over warfarin when treating a bleeding patient. However, this was a single-centre retrospective analysis with a small number of patients taking dabigatran (


Previous studies of small foreign bodies (FB) have shown a wide range of accuracies of FB detection using animal models, with high accuracy rates for FB > 10 mm and variable accuracy rates for 4 to 5 mm FB.To determine the lower limit of sonographic detection of FB using current emergency ultrasound equipment in a soft tissue model.FBs made of metal, glass, wood, and plastic (3 of each) 1 x 1 x 3 mm in size were placed at a depth of 0.5-2.0 cm in 12 pork feet. 8 feet were punctured without FB placement. Pork feet were submerged during this process to minimize air in tissue. 7 ED sonologists with > 2 years experience were blinded to overall number, type and depth of FB, but not to size. FB sites were scanned by each sonologist using either a hockey stick or traditional linear array transducer in a randomized pre-assigned order. Sonologist confidence in the diagnosis was reported using a visual analog scale for each site. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) with 95% confidence intervals were calculated. To determine if sonologist confidence differed by perceived presence or absence of a foreign body, paired t-test was used.140 ultrasound scans were performed which reported sensitivity, specificity, PPV and NPV as 50% (95% CI: 39%-61%), 50% (37%-61%), 60% (48%-72%), and 40% (28%-52%) respectively. There was little agreement among the sonologists (only 2 sites with 100% agreement). Sensitivity ranged from 25% to 75%, specificity 37% to 62%, PPV 42% to 75%, and NPV 25% to 57% for each sonologist. Sonologists were more confident reporting a positive result , irrespective of the actual presence of FB. The difference between detection rates of 4 types of FB did not reach statistical significance.Current emergency ultrasound equipment utilized by ED sonologists is unreliable in detection of 3 mm FB in a human extremity soft tissue model. Future studies may further delineate accuracy rates among different sizes and materials of FB.


Meningitis is notoriously difficult to diagnose in infancy because its clinical features are non-specific. World Health Organization (WHO) guidelines suggest several indicative signs, based on limited data. We aimed to identify indicators of bacterial meningitis in young infants in Kenya, and compared their performance to the WHO guidelines. We also examined the feasibility of developing a scoring system for meningitis.We studied all admissions aged < 60 days to Kilifi District Hospital, 2001 through 2005. We evaluated clinical indicators against microbiological findings using likelihood ratios. We prospectively validated our findings 2006 through 2007.We studied 2,411 and 1,512 young infants during the derivation and validation periods respectively. During derivation, 31/1,031 (3.0%) neonates aged < 7 days and 67/1,380 (4.8%) young infants aged 7-59 days (p < 0.001) had meningitis. 90% of cases could be diagnosed macroscopically (turbidity) or by microscopic leukocyte counting. Independent indicators of meningitis were: fever, convulsions, irritability, bulging fontanel and temperature ≥ 39°C. Areas under the receiver operating characteristic curve in the validation period were 0.62 [95%CI: 0.49-0.75] age < 7 days and 0.76 [95%CI: 0.68-0.85] thereafter (P = 0.07), and using the WHO signs, 0.50 [95%CI 0.35-0.65] age < 7 days and 0.82 [95%CI: 0.75-0.89] thereafter (P = 0.0001). The number needed to LP to identify one case was 21 [95%CI: 15-35] for our signs, and 28 [95%CI: 18-61] for WHO signs. With a scoring system, a cut-off of ≥ 1 sign offered the best compromise on sensitivity and specificity.Simple clinical signs at admission identify two thirds of meningitis cases in neonates and young infants. Lumbar puncture is essential to diagnosis and avoidance of unnecessary treatment, and is worthwhile without CSF biochemistry or bacterial culture. The signs of Meningitis suggested by the WHO perform poorly in the first week of life. A scoring system for meningitis in this age group is not helpful. Meningitis, pneumonia and sepsis in neonates and young infants (age < 60 days) are leading causes of childhood death in developing countries ,2. TheseThe WHO guidelines list 'specific'  and 'general'  signs, advising lumbar puncture (LP) if any are present . These gWe have previously identified clinical indicators of bacterial meningitis in children aged 60 days or more at our hospital in rural Kenya  and the st 2001 to July 31st 2005, and subsequently to validate the findings from January 1st 2006 to December 31st 2007. The hospital is located in a rural area on the Kenyan coast serving a population of ~240,000 who are mainly rural farmers. Malaria is endemic and children receive up to 120 infective mosquito bites per year. The government of Kenya introduced Infant vaccination against Haemophilus influenzae type b in December 2001. HIV infection is present in 6-8% of women attending the hospital antenatal clinic. There is little antibiotic pre-treatment before admission to hospital.We conducted the study at Kilifi District Hospital, Kenya. We prospectively collected data on all admissions to identify clinical indicators of meningitis from June 1We collected a standardized set of clinical and laboratory data (including a complete blood count and blood culture) from all young infants at admission . ClinicaThe indications for LP were any suspicion of meningitis or sepsis; impaired consciousness, inability to breastfeed or convulsions. We delayed LP if cardiac or respiratory compromise was present. Following admission, the clinical team reviewed all admissions at least once daily and performed an LP if they subsequently suspected meningitis. Neonates and young infants with suspected invasive bacterial infection were treated with benzyl penicillin , plus gentamicin (3-7.5 mg/kg once daily depending on age and weight) as recommended by WHO [Haemophilus influenzae type b and Streptococcus pneumoniae  were performed if the CSF leukocyte count was > 10 cells/μl [® 9050 system instrument . Pathogens in CSF or blood culture were identified by standard techniques [Cerebrospinal fluid (CSF) leukocyte count was determined with a modified Neubauer counting chamber. A Gram stain and latex agglutination antigen testing for cells/μl . CSF waschniques ,17.For this analysis, we defined meningitis as a positive CSF culture, or a positive CSF latex agglutination test, or bacteria seen on Gram stain, or a CSF total leukocyte count ≥ 50 cells/μl. Since the cut-off of ≥ 50 cells/μl was previously derived for children age ≥ 60 days,  we firstWe excluded from the analysis infants who died before an LP was performed, because we could not be certain of their meningitis status. We classified those in whom we did not perform an LP, but were discharged home well as not having meningitis. We analysed data from neonates in the first week of life separately because we hypothesized that both the aetiology and the clinical signs may differ. We investigated the diagnostic values of individual clinical features by examining their positive and negative likelihood ratios (LR) for meningitis. Variables found to have crude LRs of ≥ 1.5 or ≤0.67 were regarded as potentially useful and were adjusted for the potential confounding effects of related variables in a multivariate analysis according to the method of Spiegelhalter and Knill-Jones ,18,19. WWe derived practical screening rules from the indicators identified in descending strength of their adjusted positive LR. We then evaluated these rules by calculating the area under the ROC curves for the derivation and validation data sets. In order to examine the feasibility of developing a scoring system for meningitis, we constructed simplified scores by assigning points approximating to the natural logarithm of the adjusted likelihood ratio for each indicator. Where potential for a negative score existed, we added a constant. We also evaluated these scores by calculating the area under the ROC curves for the derivation and validation data sets. In addition, ROC curves were used to determine the cut off value with the best sensitivity and specificity in discriminating between those with or without meningitis. The negative predictive value (NPV) and the positive predictive value (PPV) were also calculated.roccomp for independent datasets, which returns a chi-squared statistic [Before undertaking the analysis, we used the method of Hanley and McNeil to determine that the validation dataset was sufficiently large to reject a null hypothesis of no prediction (ROC area = 0.5), for areas of ≥ 0.6 . ROC aretatistic . For othtatistic . We perfOf 2,877 young infants admitted in the derivation period, 1,415 (49%) were age < 7 days and 1,462 (51%) were aged 7-59 days. 2,360 (82%) were delivered at home. Among those admitted in the first week of life, half were of low weight: 269 (19%) weighed < 1.5 Kg and 427 (31%) were between 1.5 and 2.5 Kg. Among infants who died, an LP was not performed in 381/447 (85%) infants admitted in the first week of life and 85/128 (66%) infants aged 7 to 59 days. Most deaths occurred within 48 hours and 40% of all deaths were among neonates admitted on the first day of life. Amongst those weighing < 1.5 Kg, overall case fatality was 63%, mainly due to prematurity and birth asphyxia. Thus, 466 neonates and young infants died before an LP was performed and were excluded from the analysis, leaving 2,411 neonates and young infants: 1,031 (43%) in the first week of life and 1,380 (57%) aged 7 to 59 days. The flow chart of patients included in the study and the number having an LP is as shown  vs 67 (4.8%) (p < 0.001). The commonest bacterial species were Amongst infants in the first week of life, 316/1,031(31%) had a history of fever including 24/31 (77%) of those with meningitis  with meningitis had a history of fever. The absence of fever strongly predicted the absence of meningitis  sensitivity 90.8%, specificity 45.6% and did not differ between the first week of life or thereafter (p = 0.8). The WHO recommended signs had an ROC of 0.68 (95%CI 0.63-0.73) with a sensitivity 70.4%, specificity 61.9%.1,678 consecutively admitted neonates and young infants, of whom 900 (54%) were admitted in the first week of life and 778 (46%) aged 7-59 days were admitted during the validation period. Of these, 166 (10%) (141 during the first week of life and 25 thereafter) died without an LP and thus only 1,512 were included for validation. Overall 1,109 (66%) were born at home. During this period LPs were performed in 501/759 (66%) of neonates aged < 7 days and 532/753 (71%) of those aged 7 to 59 days. The overall proportion having an LP was greater in the validation period than in the derivation period (p < 0.001).Meningitis was present in 63 (4.2%), 15/759 (2.0%) in the first week of life and 48/753 (6.4%) from 7-59 days. This prevalence of meningitis did not differ to from the derivation period either in the first week of life or 7-59 days (P = 0.45 & 0.13).2 = 3.24, P = 0.07). The overall area under the ROC curve for the signs suggested by WHO was 0.74(95%CI 0.67-0.81). It was significantly different (0.50(95%CI 0.35-0.65)) in the first week of life compared to (0.82(95%CI 0.75-0.89)) after the first week of life, . The overall sensitivity using the signs we derived (78%), was not significantly different from the (70%) for the WHO signs. Likewise when applied the devised simplified scoring system to the validation data set, the best compromise on sensitivity and specificity was similarly achieved with just a cut-off ≥ 1; sensitivity 77.8%, specificity 55.2%.The overall area under the ROC curve for predicting meningitis with the indicators we had identified was 0.75 (95%CI 0.68-0.82). The area was (0.62(95%CI 0.49-0.75)) in the first week of life and (0.76(95%CI 0.68-0.85)) after the first week of life. This difference did not reach statistical significance  infants who received an LP or presumptive treatment on the basis of the signs we found compared to 28 (95% CI 19-61) using the WHO recommended signs , measured axillary temperature ≥ 39°C, agitation or irritable or report a history of fever. Infants with respiratory or circulatory compromise should receive parenteral antibiotics and an LP should be performed later to determine the duration of therapy. It is worth noting that the area under the ROC curve in the validation period using the WHO suggested signs did not significantly differ from chance (ROC area 0.5) for this age bracket. This suggests that the WHO signs may largely not be able to discriminate between those with or without meningitis in the first week of life.In young infants' age between 7 and 59 days old, there were few cases of meningitis in the absence of a history of fever. The presence of one or more of four clinical features: a history of fever, a bulging fontanel, irritability, convulsions, or an axillary temperature ≥ 39°C identified 85% of the cases of meningitis at admission. The lower sensitivity of the signs suggested in the WHO guidelines , our resWe are encouraged that the clinical signs that we identified are contained within the set of 14 signs predictive of sepsis identified from data collected in the WHO multicenter study and were specifically associated with meningitis -10. The Importantly, given the lack of microbiological laboratory resources at most hospitals in a rural African setting, clinicians may consider LP not worthwhile. However, we found that 90% of cases of meningitis in this age group are identifiable macroscopically or by basic CSF leukocyte counting. This underscores the value of undertaking LP in the absence of full biochemical or microbiological laboratory facilities.We did not perform LPs in infants with compromised respiratory or circulatory status and many infants died before LP was undertaken. It is therefore likely that we missed meningitis in some of these cases, especially on the first day of life and amongst those with very low birth weight . We excluded these cases, but it may have reduced the predictive value of the signs we examined. Future studies should explore acceptability of post mortem LPs in resource poor nations, as this may aid in acquiring more robust data. Ajayi and Mokoulu reported from Nigeria that meningitis was rare in the first week of life. However in their study, three times fewer LPs were done in infants in the first 72 hours of life . SecondlIn many hospitals in sub-Saharan Africa, neonates and young infants are initially assessed and treated by staff with little specific training or experience in neonatal or young infant care. Although clinical signs predictive of severe illness in this age bracket have been identified, previous studies did not specifically address meningitis . Given tThe authors declare that they have no competing interests.MKM provided inpatient neonatal care, data collection, conducted analysis and prepared the manuscript for submission. JAB conceived and designed the study, conducted the statistical analysis and the overall manuscript preparation. CRJCN was involved in the conception of the study, and with ME supervised clinical care and participated in analysis. AT participated in data collection and analysis. BSL was responsible for laboratory analysis and data, PJ and EW participated in patient care and data collection and manuscript preparation. All authors read and approved the final manuscript for publication. All members of the KEMRI medical, nursing, laboratory and computing team participated in patient care, data collection and data storage.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/11/301/prepub


By grinding micro-sized coarse powder with grinding beads of 50 μm in diameter, the mean hydrodynamic diameter of Cs0.33WO3 powder could be reduced to about 50 nm in 3 h, and a stable aqueous dispersion could be obtained at pH 8 via electrostatic repulsion mechanism. After grinding, the resulting Cs0.33WO3 nanoparticles retained the hexagonal structure and had no significant contaminants from grinding beads. Furthermore, they exhibited a strong characteristic absorption and an excellent photothermal conversion property in the near-infrared (NIR) region, owing to the free electrons or polarons. Also, the NIR absorption and photothermal conversion property became more significant with decreasing particle size or increasing particle concentration. When the concentration of Cs0.33WO3 nanoparticles was 0.08 wt.%, the solution temperature had a significant increase of above 30°C in 10 min under NIR irradiation . In addition, they had a photothermal conversion efficiency of about 73% and possessed excellent photothermal stability. Such an effective NIR absorption and photothermal conversion nanomaterial not only was useful in the NIR shielding, but also might find great potential in biomedical application.Cs Plasmonic nanomaterials could exhibit special absorption via the excitation of surface plasmon -3, and tPhotothermal therapy is an attractive therapy technique using photosensitizers to generate heat from light absorption and then kill the cancer cells ,11. To a0.33WO3) nanoparticles have been regarded to be highly promising in transparent solar filter application [Recently, to reduce the energy consumption for air-conditioning and decrease the emission of carbon dioxide, NIR-shielding materials have received considerable attention in the development of transparent and solar heat-shielding filters for solar control windows of automobiles and architectures -34. Amonlication -30. Beca0.33WO3 nanoparticles were prepared by a stirred bead milling process. Although Takeda and Adachi have reported the preparation of tungsten oxide nanoparticles by milling in organic medium with a dispersant agent [0.33WO3 nanoparticles without extra dispersant agents which have not been reported was attempted in this work. The appropriate pH of dispersion solution for grinding was determined, and the effect of grinding time on the size of Cs0.33WO3 nanoparticles was examined. Furthermore, the NIR photothermal conversion property of the resulting Cs0.33WO3 powder after grinding for various times was studied to demonstrate the excellent NIR photothermal conversion property of Cs0.33WO3 nanoparticles.Until now, only limited work has been reported for the solvothermal synthesis of cesium tungsten oxide nanorods . The maint agent , for fut0.33WO3) coarse powder with a primary particle size of about 1 to 2 μm were obtained from the Industrial Technology Research Institute of Taiwan (ITRI). Deionized water was produced by Direct-Q3 ultrapure water system of Millipore Co., Billerica, MA, USA. Potassium hydroxide was purchased from Wako Pure Chemical Industry Co., Ltd . Nitric acid was supplied by Merck KGaA . The yttrium-stabilized zirconia  grinding beads with a diameter of 50 μm were obtained from Toray Ind., Inc. . Polyethylene glycol 6000  was a product of Merck KGaA.Cesium tungsten oxide  was added to the aqueous solution of potassium hydroxide at pH 8, and then the dispersion was put into the stirred bead mill. An agitation speed of 2,400 rpm  was used to exert both shearing and imparting forces on the Cs0.33WO3 coarse powder and was run for different times. Samples were taken at various intervals of grinding time for particle size analysis. The filling ratio of the mill chambers by grinding beads was 60 vol.%. The mill was operated at a constant temperature of 20°C.Cs0.33WO3 nanoparticles in the aqueous dispersion were measured using a Malvern Nano-ZS dynamic light-scattering spectrometer . For the measurement of zeta potential, the concentration of Cs0.33WO3 nanoparticles was 10 mg/L, and the pH of aqueous dispersion was adjusted by the addition of potassium hydroxide or nitric acid. Transmission electron microscopy (TEM) analysis was carried out on a Hitachi model H-7500  at 120 kV. High-resolution TEM (HRTEM) image of a single Cs0.33WO3 nanoparticle and the corresponding electron diffraction pattern were observed using a Jeol model JEM-2100F  at 200 kV. The content of the contaminant ZrO2 from the stirred bead milling process was determined using an energy dispersive X-ray (EDX) spectrometer attached to the TEM. The crystal structure was characterized by X-ray diffraction (XRD) analysis on a Shimadzu RX-III X-ray diffractometer  using CuKα radiation (λ = 0.1542 nm). The absorption spectra were measured by a Jasco V-570 UV–vis-NIR spectrophotometer .The zeta potential and mean hydrodynamic diameter of Cs0.33WO3 nanoparticles was investigated in deionized water at different concentrations. The aqueous dispersion of Cs0.33WO3 nanoparticles was added to a 2-mL polystyrene cell, and then the dispersion was exposed to an 808-nm diode laser (HPM (LD1202) X26, Power Technology Inc., Little Rock, AR, USA) with an irradiation area of 0.3 cm2 and an intensity of 820 mW . The temperature of aqueous dispersion was detected with a thermocouple. Photothermal conversion efficiency was calculated using the method reported by Chen et al. [0.33WO3 nanoparticles under NIR irradiation, the aqueous dispersion of Cs0.33WO3 nanoparticles  was continuously re-exposed to an 808-nm diode laser (2.73 W/cm2) for 5 cycles. For each cycle, the aqueous dispersion was irradiated for 10 min and then cooled to the initial temperature. Using a thermocouple, the variation of temperature with time was monitored.The NIR photothermal conversion property of Csn et al. . For the0.33WO3 coarse powder was performed in aqueous solution in the absence of extra stabilizers. The resulting Cs0.33WO3 nanoparticles were stabilized in aqueous solution via electrostatic repulsion mechanism, owing to their electric double layer. Since the electrostatic repulsion was strongly influenced by the surface charge of particles, the effect of pH on the zeta potential of Cs0.33WO3 nanoparticles was investigated to determine the appropriate solution pH. As indicated in Figure 0.33WO3 nanoparticles had an isoelectric point of about pH 1.8. With increasing pH, their zeta potential decreased and then approached a constant of about −35 mV when pH was above 8. Thus, the aqueous solution for the bead milling of Cs0.33WO3 coarse powder was fixed at pH 8 by adding potassium hydroxide in deionized water.In this work, the bead milling of Cs0.33WO3 powder with grinding time. It was obvious that the mean hydrodynamic diameter of Cs0.33WO3 powder decreased quickly from about 1,310 nm to about 50 nm within 3 h, revealing that the size of Cs0.33WO3 powder could be reduced to nanoscale efficiently by the bead milling process. Inset a in Figure 0.33WO3 powder after grinding for 1, 2, and 3 h. It revealed that increasing the grinding time not only led to the decrease of hydrodynamic diameters, but also made the hydrodynamic diameter distribution become narrower. This could be reasonably referred to the fact that a longer grinding time could provide more contact between the grinding beads and the ground powder. In addition, inset b in Figure 0.33WO3 powder before and after grinding for 3 h. It was observed clearly that the aqueous dispersion of Cs0.33WO3 powder before grinding was quite unstable. They precipitated completely in a few minutes. However, after grinding for 3 h, a homogeneous and stable aqueous dispersion of Cs0.33WO3 nanoparticles with a mean hydrodynamic diameter of 50 nm could be obtained.Figure 0.33WO3 powder before grinding and after grinding for different times were shown in Figure 0.33WO3 powder before grinding had a large particle size. After grinding, the resulting particles had an irregular shape because they were debris from the collisions with grinding beads during the milling process. Furthermore, with increasing the grinding time, the particle size became smaller and more uniform. This result was consistent with the abovementioned observation of hydrodynamic diameter and confirmed that the Cs0.33WO3 nanoparticles with uniform size could be obtained by a stirred bead milling process.Typical TEM images of the Cs0.33WO3 powder before grinding and after grinding for different times. It was found that, before grinding, the characteristic peaks of Cs0.33WO3 powder corresponding to the (002), (200), (112), (202), (212), (220), (204), (312), (400), and (224) planes of hexagonal structure as indicated in the JCPDS file  were observed. After grinding, the XRD patterns had no significant change except that the characteristic peaks became broader. This revealed that the bead milling process did not result in the crystal structure change of Cs0.33WO3 nanoparticles. As for the broader characteristic, it was due to the decrease in particle size. In addition, it was mentionable that ZrO2 might be present in the Cs0.33WO3 nanoparticles as a contaminant generally because the grinding beads might be crushed during the stirred bead milling process. However, no significant characteristic peaks for monoclinic and cubic ZrO2 were observed in Figure 0.33WO3 powder than the yttrium-stabilized zirconia grinding beads; thus, it revealed that the contamination from grinding beads could be neglected.Figure (220), 20, (312), 0.33WO3 nanoparticle obtained after grinding for 3 h. The main lattice spacing of 0.375 nm is related to the (002) planes of hexagonal structure. The corresponding electron diffraction pattern was indicated in Figure 0.33WO3. In addition, the EDX spectrum was also shown in Figure Figure 0.33WO3 powders (0.008 wt.%) before and after grinding for different times were indicated in Figure 0.33WO3 powder had no significant absorption before grinding. However, after grinding, the Cs0.33WO3 nanoparticles exhibited a significant absorption in the NIR region, owing to the free electrons or polarons as discussed in the work of Takeda and Adachi [0.33WO3 powder become efficient as a transparent NIR absorption material. In addition, Figure 0.33WO3 nanoparticles with different particle concentrations obtained after grinding for 3 h. It was obvious that NIR absorption could be enhanced by increasing particle concentration. When the particle concentration was above 0.08 wt.%, the fluctuation of absorbance due to the strong absorption has reached the instrumental detection limit.The absorption spectra for the aqueous dispersions of Csd Adachi . Also, w0.33WO3 powder before grinding and after grinding for 1, 2, and 3 h were 1,310, 250, 180, and 50 nm, respectively. Their NIR photothermal conversion property in the aqueous dispersions was examined at a fixed particle concentration of 0.008 wt.%. For the samples before grinding and after grinding for 1 and 2 h, 5 wt.% of PEG 6000 was added to avoid the occurrence of precipitation. The blank solution with 5 wt.% of PEG 6000 in deionized water was also investigated for comparison. The result was shown in Figure 2) caused a temperature increase of only about 3°C after 10 min. For the aqueous dispersion of Cs0.33WO3 powder before grinding, the NIR irradiation-induced temperature increase was also slightly higher than the blank solution. However, for the aqueous dispersions of Cs0.33WO3 powder after grinding, the temperature was significantly raised under NIR irradiation. Also, with increasing grinding time, the temperature increase became more significant. For the aqueous dispersion of Cs0.33WO3 nanoparticles obtained after grinding for 3 h, the temperature increase after 10 min was 15°C. This was in agreement with the observation of absorption spectra and revealed that the NIR photothermal conversion capability of Cs0.33WO3 nanoparticles could be enhanced by the decrease of particle size.According to Figure 0.33WO3 nanoparticles with different particle concentrations obtained after grinding for 3 h is shown in Figure 0.33WO3 nanoparticles was 0.08 wt.%, the solution temperature could be raised to about 55°C after 10 min. The temperature increase was above 30°C. This was consistent with the absorption spectra as indicated in Figure 0.33WO3 nanoparticles was above 0.08 wt.%, the temperature increase could not be further enhanced. It was suggested that the absorption of NIR light by the Cs0.33WO3 nanoparticles might have reached the maximum, that is, the NIR light has been absorbed completely. This demonstrated that Cs0.33WO3 nanoparticles indeed possessed excellent NIR absorption and photothermal conversion property. Furthermore, the significant temperature increase of up to 55°C was sufficient for the killing of cancer cells [The variation of solution temperature with the NIR irradiation time for the aqueous dispersions of Cser cells ,23. Thus0.33WO3 nanoparticles (2 mg/mL) under NIR irradiation  could be determined to be 73%, close to that of gold nanorods with an effective radius of 30 nm. Because the Cs0.33WO3 nanoparticles examined had a mean hydrodynamic diameter of 50 nm and the photothermal conversion efficiency increased with the decrease of particle size [0.33WO3 nanoparticles had a photothermal conversion property comparable to gold nanorods.According to the method reported by Chen et al. , the phocle size , this re0.33WO3 nanoparticles under the irradiation by an 808-nm diode laser was also examined. As shown in Figure 0.33WO3 nanoparticles had the same photothermal conversion capability. This revealed that Cs0.33WO3 nanoparticles possessed better photothermal stability than gold nanorods under NIR irradiation. Such an excellent property makes them to become a superior candidate in NIR photothermal therapy.It was mentionable that recently, Fu et al. reported that the NIR irradiation by an 808-nm laser caused the partial melting of gold nanorods, leading to the decrease of photothermal conversion efficiency . In this0.33WO3 nanoparticles with a mean hydrodynamic diameter of about 50 nm were prepared successfully in an aqueous solution of pH 8 by bead milling. They possessed excellent NIR photothermal conversion property and stability. With decreasing particle size or increasing particle concentration, the NIR photothermal conversion-induced temperature increase is enhanced. Such a nanomaterial not only could be used in the transparent solar heat-shielding filters, but also is useful for the development of NIR-triggered photothermal conversion materials in biomedicine.Hexagonal CsThe authors declare that they have no competing interests.CJC carried out the experiments and drafted the manuscript. DHC guided the study and modified the manuscript. Both authors read and approved the final manuscript.CJC is currently a Ph.D. student of the National Cheng Kung University (Taiwan). DHC is a distinguished professor of the Chemical Engineering Department at National Cheng Kung University (Taiwan).


E. coli) infections have been increasing since 2006 inducing a specific national guideline for the prevention of ESBLE published in 2010.In France, for many years, MRSA infections have been decreasing whereas ESBLE  from 2007 to 2011 is issued from the national monitoring network of multidrug resistant bacteria in hospital (BMR-RAISIN) implemented since 2002. HCF participated within a 3 months survey period on a voluntary basis. Strains were isolated from sample issued for diagnostic purposes (a single strain of the same species per patient). Incidences of MRSA and ESBLE stratified by region were calculated per 1,000 patient-days (PD) from 2007 to 2011. An Univariate Poisson regression was used to estimate temporal trends.-3).From 2007 to 2011, 454 HCF participated each year in BMR-RAISIN network: 377 HCF with acute care unit (ACU), 165 with intensive care unit (ICU), and 354 with long-term care unit (R-LTCF). In almost all French regions (with more than 2 HCF participant), incidences of MRSA/1000 PD decreased significantly from 0.51 to 0.39 between 2007 and 2011 (p=10-3) for all French regions from 0.24 to 0.50 globally, from 0.32 to 0.65 in ACU, 1.16 to 1.91 in ICU and from 0.14 to 0.28 in R-LTCF.Overall incidences of MRSA decreased from 0.67 to 0.50 in ACU, from 1.75 to 1.04 in ICU and from 0.31 to 0.23 in R-LTCF. At the same time, EBLSE/1000 PD incidences increased significantly (p = 10Although the decrease of the MRSA incidences is encouraging, ESBLE incidences continue to increase strongly despite control efforts in all French regions between 2007 and 2011. This steady increase must incite implementation of HCF to upgrade their preventive recommended measures, in particular for contacts precautions and excreta management.None declared.


In the last years the literature suggest that the efficacy of bracing to reduce the curve progression and the surgery is good in compliant patients. Some of the studies applied a sensor other standardised form. Therefore the lack evidence of the effectiveness of bracing may partly be explained by poor compliance.The aim of the present study was to prospectively evaluate the association between compliance of brace wear and progression of the scoliotic curve including the surgical rate in patients with idiopathic adolescent and juvenile scoliosis treated with PASB, Lyon brace and Milwaukee.Prospective study from 1424 patients treated for idiopathic scoliosis between 1995 and 2013.Fulfill the inclusion criteria  683 patients. Of these, 505 patients had a definite outcome, 107 have abandoned treatment and 71 are still in treatment . The minimum duration of follow-up was 24 months. Three outcomes were distinguished in agreement with SRS criteria: curve correction, curve stabilization and curve progression. Wearing of the brace was assessed by one orthopaedic surgeon (LA) and scored on a standardized form. Scoring was based upon questioning the patient and the parents. The Compliance was reported as: Complete (used as prescribed); Incomplete A (removed for 1 month); Incomplete B (removed for 2 months); Incomplete C ; Incomplete D (only the night). The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests.The results from our study showed that at follow-up the compliance was: Complete 58%; Incomplete A 6.3%; Incomplete B 11.7%; Incomplete C 16.2%; Incomplete D 7.7%.The 505 patients with a definite outcome Cobb mean value was 29.8 ± 7.5 SD at beginning and 17.1 ±10.9 SD at follow-up. Perdriolle was 13.2 ± 5.6 SD at beginning and 7.6 ± 4.8 at follow-up.Curve correction/stabilization was accomplished in 291/293 of Complete, 32/32 Incomplete A, 55/59 Incomplete B, 79/82 Incomplete C, 37/39 Incomplete D. Surgery Referral was 3/293 of Complete, 0/32 Incomplete A, 0/59 Incomplete B, 2/82 Incomplete C, 2/39 Incomplete D.We conclude that the risk for curve progression and surgery are reduced in patients with high brace compliance. In particular the abandon of treatment for only 1 month is not influence for the good results while wearing the brace only the night time increased curve progression.


GJB2) to the genetic load of deafness and its mutation spectra vary among different ethnic groups.The contribution of Gap junction beta-2 protein  among GJB2 mutations, followed by p.R143W (26.8%) and p.V37I (9.8%). Among those probands without the p.V37I allele in a trans configuration who showed some degree of residual hearing, the mean air conduction thresholds at 250 and 500 Hz were 57 dB HL and 77.8 dB HL, respectively. The c.235delC mutation showed a particularly wide spectrum of hearing loss, from mild to profound and significantly better hearing thresholds at 250 Hz and 2k Hz than in the non-p.V37I and non-235delC nonsyndromic hearing loss and deafness 1(DFNB1) subjects.Of the 130 subjects, 22 (16.9%) were found to carry at least one mutant allele of Despite its reputation as the cause of severe to profound deafness, c.235delC, the most frequent DFNB1 mutation in our cohort, caused a wide range of hearing loss with some residual hearing in low frequencies. This finding can be of paramount help for prediction of low frequency hearing thresholds in very young DFNB1 patients and highlights the importance of soft surgery for cochlear implantation in these patients. The incidence of profound pre-lingual hearing loss is about 1 per 1000 at birth and 1 per 300 children by 4 years of age .GJB2) , which encodes connexin 26, are responsible for nearly half of the cases of hearing loss in many populations ) and p.V37I (4/41 [9.8%])  . The mos [9.8%]) . These tr cohort .GJB2 mutation (+) group (n = 22) consisted of 14 males (63.6%) and 8 females (36.4%) with ages ranging from 9 months to 25 years; 95.5% (21/22) of the subjects were within the age range of 0–15 years. The mean age at recruitment to the study was 3.1 (±3.5) years. Among these 22 subjects, 19 subjects were confirmed to be DFNB1, carrying two mutant alleles of GJB2 either as a homozygous or a compound heterozygous state  showed clearly better hearing thresholds than the other DFNB1 subjects (trans configuration with p.V37I showed the best threshold (mean threshold: 24.2 dB), as compared to the other subjects with p.V37I  exhibited a mean hearing threshold of 93.5 dB , again csubjects . Breakinquencies . Althougquencies . When wequencies .GJB2 are known to be responsible  for non-syndromic SNHL, which is commonly related with a severe to profound degree of autosomal recessive inheritance ..GJB2 mutGJB2 mutant alleles associated with the better residual hearing.Furthermore, two homozygotes for c.235delC showed a significantly different degree of SNHL . Such phGJB2-related hearing loss showed a better auditory outcome after cochlear implantation than age-matched children [GJB2 can potentially provide us the clue to the audiologic phenotype, especially at low frequencies which is sometimes not feasible to evaluate in infants.The presence of residual hearing can affect the planning and placement of cochlear implants. Recent studies demonstrated that children with children . This wachildren  or an ischildren , 40. OurGJB2 mutations. This can be of importance when planning the insertion depth of cochlear implants in infants, in whom the measurement of low-frequency hearing thresholds may not be feasible.This study showed wide range of hearing loss and low frequencies residual hearing in the DFNB1 subjects with the c.235delC mutation. Especially for patients with residual hearing, it is important to try to preserve this residual hearing during cochlear implantation. Clinicians should keep in mind that there may be substantial residual hearing, especially at low frequencies, in DFNB1 subjects related to c.235delC in Koreans. A further study with a larger cohort and more longitudinal data will improve our knowledge on the residual hearing associated with various S1 FigAll three patients showed profound hearing loss and, rarely, residual hearing.(TIF)Click here for additional data file.


In spite of advances in control of infections, wound infections have not completely controlled due to many reasons. The widespread uses of antibiotics, together with the length of time over which they have been available have led to major problems of resistant organisms contributing to morbidity and mortality. This study was aimed to assess bacterial isolates and their drug susceptibility patterns from patients with pus and/or wound discharge.A retrospective study was conducted at Gondar University Hospital from all individuals who provide pus and/or wound discharge sample from September, 2009 to August, 2012. Socio-demographic and laboratory results were collected from the University Hospital Microbiology Laboratory unit registration books by using a standard data collection format. Data were analyzed using SPSS version 20 software. P-value ≤ 0.05 was considered statistically significant.Staphylococcus aureus (32.9%), Coagulase Negative staphylococci (14.7%), Streptococcus spp. (11.6%), Escherichia coli (9.5%), Klebsiella spp. (6.3%). The result showed that 66.2% of the isolates were resistant to tetracycline, followed 59.8% for ampicillin, 59.1% for cotrimoxazole, 51.7% for penicillin; least resistant being 6.3% for gentamycin.A total of 628 study subjects were included in the study with bacterial isolation rate of 441 (70.2%). Of all, 344 (54.8%) were males. Two hundred eighty two (63.9%) of the isolates were gram positive and 159 (36.1%) were gram negative. About 331/ 441 (75.0%) of the total isolates were S. aureus being the dominant. Most of the isolates were resistant to many of the antibiotics tested where all isolates of Pseudomonas spp. being resistant to two or more antibiotics. Antibiotic susceptibility test is necessary for effective control of wound infections.High prevalence of bacterial isolates were found;  Infectious diseases still remain an important cause of morbidity and mortality among humans, especially in developing countries. Various species of bacteria live on human skin, gastrointestinal tract, in the nasopharynx and other parts of the body with less potential for causing disease because of first line defense within the body. Skin abrasion due to surgical procedure, trauma, burns, diseases, nutrition and other factors affect this first line defense and leads to microbial contamination results infections . As wounThe problem of hospital acquired infection remains a serious health hazard worldwide. As described by World Health Organization (WHO) , it is oKnowledge of the causative agents of wound infection has proven to be helpful in the selection of appropriate antimicrobial therapy and on infection control measures taken in health institutions . Therefo2 enriched environment), blood agar and MacConkey agar. Plates were incubated at 37°C of 24 hours. Once pure colonies identified series of biochemical tests were performed for the isolation of the species following standard procedures [A retrospective study was conducted at Gondar University Hospital from September, 2009 to August, 2012. Gondar University Hospital is a teaching hospital that provides health service to over five million inhabitants in Northwest Ethiopia. All individuals who provide pus and/or wound discharge sample at Gondar University Hospital during the study period were the participants. Socio-demographic and laboratory results were collected from the University Hospital Microbiology Laboratory unit registration books by using a standard data collection format after checking the completeness of the data. Wound swabs and discharges were aseptically collected using sterile swab in a test tube and inoculated on to chocolate agar  plates as recommended by the Clinical and Laboratory Standards Institute (CLSI) . The isoData were cleaned manually and entered and analyzed by using SPSS version 20 software. Odds ratio and Chi-square test were employed. P-value ≤ 0.05 was considered statistically significant.Ethical clearance was obtained from the Institutional Review Board of University of Gondar. A supportive letter was also obtained from College of Medicine and Health Sciences and the University Hospital clinical director before collecting the data.Staphylococcus aureus, Coagulase Negative Staphylococci (CNS), Streptococcus spp, Escherichia coli and Klebsiella spp. Among these S. aureus accounts 32.9% followed by CNS (14.7%), Streptococcus spp. (11.6%), E. coli (9.5%), Klebsiella spp. (6.3%), streptococcus pyogenes (4.8%), Pseudomonas spp. (1.8%).A total of 628 study subjects were included in the study. Among these, 284 (45.2%) were females and 344 (54.8%) were males with the age range of 1 month to 81 years. Among 628 study subjects, bacterial pathogens were isolated from 441 patients with the isolation rate of 70.2% [Table S. aureus were tested for Methicillin susceptibility, of which, 4 (20%) were resistant and 16 (80%) were sensitive.Most of the isolates were resistant to many of the antibiotics tested. The result showed that 66.2% of the isolates were resistant to tetracycline, followed 59.8% for ampicillin, 59.1% for cotrimoxazole, 51.7% for penicillin; least resistant being 6.3% for gentamycin. Among isolates tested, 18.3% of the isolates are becoming resistant to ceftriaxone and 33.3% for vancomycin [Table Pseudomonas spp, (100%); followed by S. pyogenes (85.8%); Enterobacter spp. (84.2%); and E. coli (83.4%). Fifty (11.3%) of the isolates were sensitive to all drugs tested and 68 (15.4%) were resistance to only one drug. However, among the total isolates, 323 (73.3%) of them were resistant for two or more drugs tested and 91 (20.6%) were resistant to more than 5 antibiotics tested. All isolates (100%) of Pseudomonas spp. were resistant to 2 or more antibiotics followed by S. pyogenes 85.8%, Enterobacter spp. 84.2%, E.coli 83.4%, Streptococcus spp., 82.3%, S. aureus 67.6% [Table Among resistant isolates to more than one antibiotic, the most common pathogen was E. coli 8.4%. FiftThe majority of the isolates were in the age range of 21 to 30 years which was 113 (25.6%) followed by in the age range of 1-10 years which was 95 (21.5%); age range of 11-20 which was 70 (15.9%) Table .Table 4When we compared the culture positivity of the samples, pus /discharge samples were 2.38 times positive for bacterial isolates than wound swab samples . Females were found to be 5.16 times more at risk to get infection than males . Age was also found to have significant association with a p-value of 0.003 [Table et al. in the same hospital [S. aureus, which was 32.9%, this was consistent with reports from India 30.1% and lower than Gondar hospital 65% [S. aureus is predominant in both reports, the rate of isolation declined compared to the previous reports which was 65% [Among 628 study subjects, bacterial pathogens were isolated from 441-patients with the isolation rate of 70.2%. This was higher than the results reported by Mulu hospital . This vaital 65% . AlthougPseudomonas spp., 100%; followed by S. pyogenes 85.8%; Enterobacter spp. 84.2%; and E. coli 83.4%. Fifty (11.3%) of the isolates were sensitive to all drugs tested and 68 (15.4%) were resistance to only one drug. However, among the total isolates, 323 (73.3%) were resistant for two or more drugs tested and 91 (20.6%) were resistant to more than 5 antibiotics tested. This finding was supported by other studies done in Ethiopia [Most of the isolates were resistant to many of the antibiotics tested. The result showed that 66.2% of the isolates were resistant to tetracycline, followed 59.8% for ampicillin, 59.1% for cotrimoxazole, 51.7% for penicillin; least resistant being 6.3% for gentamycin. Among isolates tested, 18.3% of the isolates are becoming resistant to ceftriaxone and 33.3% for vancomycin. Among resistant isolates to more than one antibiotic, the most common pathogen was %. Fifty .3% of thEthiopia .The majority of the patients who were positive for wound culture were in the age range of 21 to 30 years, which was 113 ; age range of 11-20 which was 70 (15.9%). Among 441 isolates, 194/334 (58.1%) were from male and 247/284 (86.9%) were from female patients. These results demonstrate that being female is found a risk factor for getting an infection by bacteria. Females were found to be 5.16 times at risk to get infected by bacteria than males. When we compared the culture positivity of the samples, pus/discharge samples were 2.38 times positive for bacterial isolates than wound swab samples. As to the limitation of this study; since it is a retrospective study some of the data registered were not as to the standard and were not included. We also fail to include more variables because of unavailability.S. aureus being the dominant. Most of the isolates were resistant to many of the antibiotics tested where all isolates of Pseudomonas spp. being resistant to two or more antibiotics. It is, therefore, necessary to do an antibiotic susceptibility test before drug prescription to effectively control wound infection.High prevalence of bacterial isolates were found from patients who provide pus and/or wound discharge sample in the study site


To investigate clinical features of infectious endophthalmitis over five years in a South Korean population.Medical records of consecutive patients diagnosed with infectious endophthalmitis at eight institutions located in Gyeongsangnam-do and Pusan city between January 1, 2004 and July 31, 2010 were reviewed.A total of 197 patients were diagnosed and treated. An average of 30.0 infectious endophthalmitis per year was developed. The annual incidence rate of postoperative endophthalmitis during 2006 ~ 2009 was 0.037%. The ratios of male to female and right to left were 50.2%: 49.8 % and 54.8%: 43.2%, respectively. Eighth decade and spring were the peak age (36.6%) and season (32.0%) to develop the infectious endophthalmitis. The most common past history in systemic disease was hypertension (40.4%), followed by diabetes (23.4%). Cataract operation (60.4%) was the most common cause, among which most of them was uneventful phacoemulsification (95.9%). Corneal laceration (51.6%) and liver abscess (42.9%) were the most common causes of traumatic and endogenous endophthalmitis, respectively. The percentages of patients with initial and final visual acuity less than counting fingers were 62.6% and 35.2%, respectively. Treatment with vitrectomy with or without intravitreal antibiotics injection was administered to 72.6% of patients, while 17.3% received intravitreal antibiotics only.Our study revealed that the development of infectious endophthalmitis was related with seasonal variation and increased during our study period. Pars plana vitrectomy was preferred for the treatment of infectious endophthalmitis in South Korea. Infectious endophthalmitis, a serious intraocular inflammatory disorder that results from the exogenous or endogenous spread of infectious microorganisms into the eye , most coAmong several prominent endophthalmitis studies, the endophthalmitis vitrectomy study (EVS), a five-year, prospective, randomized, multicenter study, demonstrated the characteristics of postoperative infectious endophthalmitis in the USA. Recently, a multicenter infectious endophthalmitis epidemiologic study in Sweden was published . Such stThe present study included eight institutes based on their ability to perform pars plana vitrectomy and microbial culture and sensitivity testing to determine the clinical features and treatment pattern of infectious endophthalmitis over five years in South Korea population.This study was a retrospective, multicenter, consecutive longitudinal cross-sectional study based on the medical records of eight South Korean institutions from January 1, 2004 to July 31, 2010. Clinical and demographic data for all patients diagnosed by infectious endophthalmitis during that period were analyzed. The protocol of this study adhered to provisions of the Declaration of Helsinki, and was approved by the Institutional Review Board of Gyeongsang National University.The following post-treatment data from ophthalmic centers at each institute were evaluated with the consensus protocol: case numbers of presumptive and culture-positive endophthalmitis; date of occurrence; sex; laterality; age; seasonal occurrence; past medical history; cause of infection ; duration of symptoms; interval between symptom occurrence and initial eye examination; preoperative visual acuity; final visual outcomes, which were defined as the best corrected vision achieved after at least one month of follow-up; treatment modality; topical, intravitreal, and systemic antibiotic selection; and culture positivity depending on the culture specimen and surgical tool. Visual acuity based on the Snellen chart was converted to log-MAR (log of the minimum angle of resolution) acuity for this analysis. For statistical analyses, Counting fingers was converted to 1.9 logMAR acuity. Hand movement, light perception and no light perception was converted to 2.3, 2.7, and 3.0, respectively .The diagnosis of infectious endophthalmitis at each institute was based on patient’s clinical symptoms and signs. Presumptive endophthalmitis was confirmed by culture. Briefly, cultures were assessed from direct smears of aqueous or vitreous humor. Growth was tested on blood agar, chocolate agar, and thioglycolate broth. Cultures for fungi were performed at room temperature on Sabouraud agar without cycloheximide.We also used data recorded between 2006 ~ 2009 in the national health claim database obtained from the Health Insurance Review and Assessment service of Korea (KIRA) to estimate the annual and monthly incidence of cataract operation . The annA total of 197 patients were diagnosed and treated with infectious endophthalmitis. Aqueous humor or vitreous was cultured in 174 patients (88.3%), and 103 (59.2%) of them had positive results. Average presumed endophthalmitis incidence was 30.0 cases per year in Busan and Gyungsangnam-do area , left (43.2%), and both (2.03%). Peak age of patients was eighth decade (36.6%), and mean age (standard deviation) was 66.9 (±15.3) years , diabetes (23.4%), liver disease (4.1%), cerebral infarction (3.5%), cardiac disease (2.9%), respiratory disease (2.3%), malignant tumor (2.3%), pulmonary tuberculosis (1.8%), kidney disease (1.8%), and others (4.7%). On the other hand, 35.6% of patients had no history of systemic diseases. No record of past medical history was found in 13.2% of patients.The most common cause of infectious endophthalmitis was cataract operation (60.4%), followed by trauma (15.2%) and endogenous (10.7%). Figure  Most of Most of the infectious endophthalmitis patients (85.5%) developed symptoms within two weeks after the event, and the peak period was 1–3 days , and the mean final visual outcome was 1.46 (±1.04). The distributions of the initial and final visual outcomes are shown in Figure As primary treatment for infectious endophthalmitis, combination of vitrectomy and intravitreal antibiotics injection simultaneously were chosen in 65.5% of patients 129/197), but intravitreal antibiotics injection only was used in 17.3% (34/197) , which was followed by Staphylococcus epidermidis 18.8% (18/96) and Other Coagulase (−) staphylococcus 10.4% (10/96) [Overall positive culture rate in this study was 103/174 59.2%). Positive culture rates varied depending on the culture method as follows: vitreous sampling before vitrectomy (50%), aqueous humor before intravitreal injection or vitrectomy (39.5%) and vitreous before intravitreal injection (37.5%). (Table %. Positi (10/96) .Table 2http://www.koreamed.org/), Pubmed (http://www.ncbi.nlm.nih.gov/), and the search engine of The Korean Ophthalmological Society  with term “infectious endophthalmitis”. This search revealed 11 articles, excepting case reports [Our literature search of infectious endophthalmitis studies in a Korean population included Korean Med .Age over 85 years is a known risk factor for postoperative infectious endophthalmitis ,21,22. IMedical history of the patients was most frequently hypertension (40.4%) and diabetes 23.4%). These findings are generally in accordance with previous studies that found hypertension in 39.8% and diabetes in 13.8% 3.4%. The,9. InterCataract surgery was the most common cause of infectious endophthalmitis, among which 95.9% of the operations were uneventful phacoemulsifications without anterior vitrectomy. Recent studies showed similar data ,22.In 84 of 152 cases (55.3%), signs of endophthalmitis occurred within 3 days after the inciting events, and 130 of 152 cases (85.5%) had signs of endophthalmitis within 14 days after the inciting events. This range was also in accordance with a previous study . In 128 Enterococcus faecalis was the most common causal bacteria in this study [Enterococcus species, was worse than EVS and Netherland, even though all of these studies included post-cataract operation endophthalmitis. In 40 of 135 cases (29.6%), the visual outcome was 20/40 or better [The final visual outcome in this study was worse than previous studies ,23,26. Ois study . RecentlThe rate of vitrectomy was 143 of 197 cases (72.6%), and the rate of only intravitreal antibiotic injection was 34 of 197 cases (17.3%). And the rate of vitrectomy as a primary treatment for infectious endophthalmitis was 65.5%. Even though the suggestion of the EVS study on postoperative endophthalmitis treatment, the surgeons who took part in this study preferred vitrectomy as the primary treatment rather than intravitreal antibiotic injection. The rate of vitrectomy as an early intervention in Netherland study was 25 of 250 cases (10%). However, the rate of vitrectomy in a recent Korean endophthalmitis study was 76.3%, which was similar to our current findings .Culture positivity in our study was 103 of 174 cases (59.2%), which corresponded with the rates (54.4-69.3%) of the previous studies ,26-29. TInfectious endophthalmitis could have different presentation, causative agents and therapeutic approaches depending on their different etiologies such as postoperative, traumatic, and endogenous endophthalmitis. Except the incidence of postoperative endophthalmitis, all kinds of infectious endophthalmitis were included and analyzed in this study. In this regards, the data in this study should be carefully interpreted and compared with the others results.This study of infectious endophthalmitis in South Korea over 5 years revealed several features showed different from the previous studies that visual outcome was worse, the vitrectomy was preferred for a primary treatment option for infectious endophthalmitis, seasonal variation was related with the development of postoperative infectious endophthalmitis. Moreover, it is also worthy to comment the increase of postoperative infectious endophthalmitis during 2007 ~ 2009 in our study. Further studies will be carried out for those differences and the cause of the increase of postoperative infectious endophthalmitis.


Estimation of heart and liver iron concentrations using T2* has become an essential diagnostic step in the management of iron overload. One of the limitations of more widespread use of these techniques has been calculating the T2* values from the original images due to need of special training and dedicated softwares. We sought to assess whether the use of an automated T2* in-line calculation protocol applied in a multicenter study in centers with different initial experience in this technique would be feasible and accurate.Seventy-six patients of the multicenter study All Iron Detected (AID) involving seven centers using different 1.5T scanners from a single vendor (Siemens AG) were included. Automated T2* maps were calculated in-line based on a prototype evaluation using original multi-echo images of the heart and liver with values obtained by drawing a region of interest in each organ directly in the originated map. Manual calculation of these values were also obtained by fitting the decay curves of the original images using the truncation method both locally as well as in a central core lab. Sixteen patients had repeated scans using a routine protocol with manual evaluation for comparison. Values of the automated pixel-wise fit T2* of the heart and liver were compared to the local manual ROI-fitting technique as well as the central core lab results values using Bland-Altman plots and intraclass correlation coefficients (ICC). Inter-scanner coefficients of variation among the repeated scans using the automated versus manual calculations was also assessed.The mean age of the patients was 32.1±23.1 years  with median automated T2* values of 31.1ms (range 4.2 to 61ms) for the heart and 5.5ms (range 0.7 to 32.4ms) for the liver. In the heart, the automatically calculated T2* values were significantly correlated to both local and core lab manual calculations, with a mean difference of -2.0ms (95%CI -2.9 to -1.1 ms) for the core lab comparison and ICC of 0.95 (95%CI 0.89 to 0.97). In the liver, the mean difference was 0.18ms (95%CI -0.03 to 0.39ms) with ICC of 0.99 (95%CI 0.991 to 0.996) comparing automated versus core lab manual measurements despite a lesser degree of agreement in patients with severe liver iron concentration (T2* < 1.8ms) with 0.5ms (95%CI 0.23 to 0.80ms) and ICC of 0.22 (-0.35 to 0.64). In the inter-scanner comparison, the coefficient of variation among the subgroup tested was 12.8% for the heart and 14.1% for the liver.The use of automated T2* maps for iron overload assessment of the heart and liver is feasible across different centers and results in accurate results compared to the traditional manual evaluation by a central core lab.N/A.


Cheilospirura hamulosa on the basis of light and stereoscopic microscopy and also camera lucida. Specimens were recovered after necropsies of 100 partridges (Alectoris chukar) from Taleqan County in Alborz Province, Iran. The prevalence of C. hamulosa in partridges was of 30% with a mean intensity of 3.9 and range of infection of 1–12. The mean length and width of females were 17.5 ± 2.14 and 0.39 ± 0.04 mm, while those of males were 12.2 ± 0.67 and 0.3 ± 0.06 mm, respectively. The characteristic digitiform tail was observed in females, and the unequal spicules, caudal alae, and ten pairs of caudal papillae were seen in males. The taxonomic characteristic longitudinal cordons and muscular and glandular oesophagus were observed in both sexes. Ratio between cordons and body length in males and females was 1 : 1.33 and 1 : 1.68, respectively. Ratio between long and short spicules in males was 1 : 2.3. The average size of embryonated eggs was 51.25 × 29.5 μm. In the present study, C. hamulosa (Nematoda: Acuarioidea) is recorded for the first time from partridges in Iran. Therefore, the morphological characters described in this study will be useful in the future diagnostic and taxonomic studies of Acuarioidea family.This study reports data on the prevalence, morphology, and morphometry of the nematode Cheilospirura hamulosa, “Diesing, 1861” (syn. Acuaria hamulosa), is a species of Acuariidae family and etiological agent of cheilospirurosis in birds such as chickens, turkeys, pigeons, and guinea fowls [ Cheilospirura hamulosa has cylindrical body with two triangular lips and 4 cuticular cordons that extend near posterior extremity. Male worms have two distinctly unequal and dissimilar spicules. Female worm tails are curved ventrally and digitiform [The parasitic nematodeea fowls . Cheilosgitiform , 4. C. hamulosa is located under gizzard cuticle mainly in koilin or muscular wall of the host [Melanoplus, Oxyanitidula, and Spathosternum parasinifrum), beetles, and weevils are intermediate hosts for C. hamulosa and birds acquire their infections by eating contaminated arthropods containing infective third-stage larvae [ C. hamulosa has veterinary and public health importance. Cheilospirura hamulosa can cause several complications such as granulomas and nodules that lead to anemia, impotence, and mortality in chickens [ Cheilospirura hamulosa may cause zoonosis and has been recovered from a nodule on the conjunctiva of a Filipino farmer [ Cheilospirura hamulosa infection in partridges (Alectoris chukar) using morphological-based methods, in Taleqan County of Iran.Thethe host , 2. Thise larvae . Due to o farmer . The preo farmer , whereasThe study was conducted in Taleqan County. This area is located in Alborz Province and its height is 1900 m above the sea level. Latitude and longitude of Taleqan are 36 degrees 15′N and 50 degrees 46′E, respectively.One hundred partridges were collected from Taleqan mountainous region between 2011 and 2013. Every year from the end of September to the beginning of February a license is issued by the Environment Protection Agency (EPA) of Iran for hunting partridges. Every hunter has permission to hunt the maximum of three partridges weekly. For this research, the gizzard of each partridge was removed from the alimentary tract and delivered to the helminthology laboratory of Shahid Beheshti University of Medical Sciences. The gizzards were examined macroscopically and then dissected in a 0.85% NaCl solution  to remove cuticle. Worms were visible to the naked eye. The worms were rinsed in normal saline and fixed in Alcohol-Glycerin  solution. Nematodes were elucidated with acetic acid and phenol, mounted in Canada balsam. Helminthes were counted and identified under light microscopy  and stereoscopic microscope  and traced by camera lucida . The morphological identification of the nematodes to the species level was done according to methods described by Skrjabin et al. . C. hamulosa was 30% with a mean intensity of 3.9% and range of infection of 1–12. A total of 116 worms were recovered from partridges. Among the recovered helminthes, 60.3% were female and 39.7% male. The specimens of C. hamulosa were found free under the gizzard cuticle, partially or fully burrowed in the walls . Muscular oesophagus was 0.37–0.38  long. Glandular oesophagus was 1.6–2.4  long. Length of total oesophagus was 1.97–2.78 . The mean of cordons length was 9.2 ± 0.28, ratio between cordons and body length was 1 : 1.33 (n = 1). In each worm there were ten pairs of caudal papillae: three couples were observed in precloacal, two pairs in adcloacal, and five couples in postcloacal . Muscular oesophagus was 0.29–0.75  long. Glandular oesophagus was 2.1–2.7  long. Length of total oesophagus was 2.39–3.05 . The mean of cordon length was 12.96 ± 0.72, and ratio between cordons and body length was 1 : 1.68. The females were amphidelphic, and their vulva is located slightly posterior to the middle of the body at 2.29 ± 0.92 from the posterior end, circular sphincter 0.064 × 0.065, tail 0.44 (n = 1) long  long . C. hamulosa reported herein is reported for the first time from partridges in Iran. Studies on this nematode in Iran only was carried out in native fowls. The partridge (Alectoris chukar) is the most important bird hunted in Iran. In the present study, prevalence of C. hamulosa in the partridge was 30% with a mean intensity of 3.9% and range of infection of 1–12.The nematodePhasianus colchicus) with a mean intensity and range of infection of 1.5, 1-2, respectively. In domestic chickens , the prevalence, mean intensity, and range of infection were 26.7%, 4 and 1–12, respectively [ C. hamulosa in indigenous fowl has shown an overall prevalence of 3.5% (17/478) [ C. hamulosa in guinea fowls  from Ghana and chickens in Zimbabwe and Cuba was 37.8%, 46.6%, and 84.6%, respectively [ C. hamulosa on native fowls from Golestan Province in north of Iran was 4% which is significantly lower than our result, because the study population is completely different from our study [The reported prevalence of this nematode by Menezes et al.  in Brazi(17/478) . The preectively –13. Thes Acuaria (Cheilospirura) are parasitic among different families of birds and they are located under the koilin layer usually in the cardiac or pyloric regions [ C. hamulosa were found under the gizzard cuticle, partially or fully burrowed in the walls of the organ   in poultry and wild bird population and very limited prevalence data of these helminthes in Iran, further study will be needed on different aspects of Acuarioidea family including pathogenesis and their prevalence in other avian species.Due to the significant pathogenic effects of these nematodes ( Cheilospirura hamulosa from partridges in Iran. The morphological characters described in this study will be useful in the future diagnostic and taxonomic studies of Acuarioidea family.In the present study, we report for the first time the isolation and morphological characterization of