Some studies have shown evidence that the prophylactic use of bethanechol chloride (BC) may be useful in preventing the incidence and/or severity of xerostomia (XT). However, the indication of BC in irradiated patients with XT needs to be better characterized. The study aimed to evaluate the influence of BC on XT, salivary flow rate, and salivary composition in patients previously submitted to head and neck radiotherapy.Forty five irradiated patients complaining of XT used 50 mg/day of BC for 3 months, and the salivary parameters were evaluated in 4 Phases . Biochemical analysis included buffering capacity; pH; total protein concentration (TP); amylase concentration (AM); catalase (CAT) and peroxidase (PX) activities. In addition, unstimulated and stimulated salivary flow rates were determined and XT was classified.p<0.05).According to the XT grading system used, patients showed improvement in XT between Phase 1, and Phases 2, 3 and 4. In addition, some changes were observed in TP concentration (decreased); AM concentration (increased); and PX and CAT activities  after Phase 2, for stimulated saliva collection (Our results suggested that when BC was used to treat salivary gland dysfunction induced by head and neck radiotherapy, improvement in XT symptoms, and some changes in saliva composition were shown.Key words:Radiotherapy, xerostomia, hyposalivation, saliva, biochemistry. The radiotherapy (RT) is indicated as primary, adjuvant to surgery, or palliative therapy for tumors in the head and neck region . HoweverXT may cause an important impact on patients’ quality of life, mainly because it may last throughout their entire lifetime . Xerostoet al. , a cholinergic agonist, has been considered an option to increase the salivary flow rate during head and neck RT, because it has fewer side effects than pilocarpine ,10. ReceThis interventional study was conducted at the University of São Paulo from March 2013 to January 2015. The ethics committee approved this study (Nº 166.104) and written informed consent was obtained from all patients. All procedures performed in this study, involving human participants, were in accordance with the ethical standards of the institutional and national research committee and with the Helsinki Declaration of 1975 as revised in 1983.- PatientsThis interventional study enrolled 45 patients of the “Liga Interdisciplinar de Neoplasias Bucais” (LINB) of the University of São Paulo, who were submitted to head and neck RT with a minimal dose of 60Gys; and complained of xerostomia. All the patients were assessed for eligibility. The grade of XT was evaluated monthly, from baseline to 3 months after treatment, using Eisbruch’ scale . Exclusi- Study design This study was designed to test BC therapy after head and neck RT, therefore, the follow up time was 3 months, divided into four Phases: before BC administration (Phase 1) and after 1 Phase 2), 2 (Phase 3) and 3 (Phase 4) months. Phases 2, 3 and 4 were compared with Phase 1 in all the statistical tests. According to the ethical principles Phase 1 (assessments before BC administration) was used as a control parameter for the subsequent Phases (after BC administration). The 3 months follow-up was chosen according to the evidences and effectiveness of BC treatment found in a similar study . Bethanechol toxicity was scored using National Cancer Institute Common Terminology Criteria for Adverse Events - NCI CTCAE, v3.0 ,13. Thiset al.  sGrade 1: mild dryness with no disability.Grade 2: dryness requiring additional fluids for swallowing.Grade 3: dryness causing dietary alterations, interference with sleep, speaking or other activities.To compute the correlation between XT and the Phases, mild XT was considered Grade 1 and severe XT, Grade 2 or 3.- Saliva collectionSialometry was evaluated by unstimulated whole saliva (UWS) and stimulated whole saliva (SWS). Saliva was collected in all the experimental time intervals; always in the morning, between 8h30 a.m. and 11h30 a.m., to minimize the effects of the circadian rhythm in salivary glands. All patients were instructed not to eat, drink or smoke 1 hour before saliva collection. In all types of collections, the patients were placed in a comfortably seated position and asked to swallow any saliva in the mouth, immediately before the tests. For the UWS, the patient started spitting the spontaneously produced saliva into a plastic funnel connected to a graduated tube, for 10 minutes. The last collection was SWS, using one drop of solution of citric acid on the dorsum of the tongue every 30 seconds for 10 minutes, then the patients were instructed to spit the saliva into another tube . After c- Biochemical analyses pH and Buffer Capacity: To evaluate buffer capacity and pH, 0.5 mL of UWS samples were used to perform the pH analysis by means of a Digimed 2D portable pH meter, immediately after the saliva collections. After this, the buffer capacity was evaluated by titration of the sample with a HCl 0.01 N solution. Before measuring began, the pH meter was calibrated with standard pH solutions at the values 7.0 and 4.0. The buffer capacity was expressed by the quantity of HCl required to decrease the sample pH to 4.0.et al.: The TP in saliva was determined by the Lowry et al. (1951) met al. (Amylase (AM): This was determined by Bellavia et al.  (1979) .et al. (Peroxidase (PX) and Catalase activity (CAT): PX was determined according to Anderson  1986) a86 aet alet al.  (1984) .- Statistical AnalysesStatistical analyses were performed using Minitab 16.1 and MedCalc 15.2.2 software packages. The McNemar test was applied to compare results of XT grades in each Phase. After this, Biochemical and Sialometry data were submitted to analysis of variance followed by 2 sample T tests. All the results were obtained with a confidence interval of 95%.A total of 45 patients were assessed and all completed Phase 1; 41 completed Phase 2 ; 37 completed Phase 3 (4 did not keep the appointment); and 30 completed Phase 4 . A total of 15 patients did not complete all Phases of the study (a side effect of BC was considered in only 2 patients) .- Xerostomia evaluation:During Phase 1 (before BC therapy), most of the patients had severe XT (93.3%); only 3 patients (6.7%) presented XT Grade 1. There was a gradual improvement in the grade of XT during the next 3 Phases of the study. In Phases 2, 3 and 4, the percentage of severe XT decreased to 80.5%, 75.7% to 70%, respectively. Inversely, mild XT increased from 19.5% (Phase 1), to 24.3% (Phase 2) and to 30% (Phase 3) Fig.  When mild XT was compared with severe XT, there was significant improvement between Phase 1 and others .- Sialometry evaluation:The sialometry results, for both UWS and SWS, showed no significant differences in the experimental time intervals (Phase 1 to 4) .- Biochemical analyses:Buffer capacity and pH values showed no significant difference between the Phases . Howeverp<0.0001); decrease between Phases 1 and 3 (p<0.0001); Phase 4, showed a return to values similar to those in Phase 1 (p=0.51)  .p=0.026); 3 (p=0.007) and 4 (p=0.018) (p=0.003); 3(p=<0.0001); and 4 (p=0.003)  . For SWSp=0.003) .p<0.05) (p<0.0001) and 4 (p=0.003)  . Howeverp=0.003) .p=0.002); 3 (p<0.0001) and 4 (p=0.029); (p<0.0001) (Amylase: There was an increase of AM concentration in UWS collection between the Phases 1 and 2(=0.029); . For SWS<0.0001) .Recently, our group demonstrated the benefits of BC used as prophylactic therapy to prevent radiotherapy-induced XT, mainly in patients treated with IMRT. However, in some patients their XT scores increased after they stopped taking the drug, therefore the duration of BC administration needs to be better defined . In the et al. (p=0.001) after BC therapy in irradiated patients. Later, Grosky et al. (p=0.01). Jham et al. (p = 0.03). In a recent double-blind study, our group showed that the prophylactic use of BC during the RT showed significant efficacy in preventing severe XT (p<0.001) and hyposalivation (p<0.05)  sy et al.  2004) cm et al.  (2007) f004 cm etet al.  rMoreover, PX concentration decreased in all Phases of the study and CAT increased after Phase 3 in SWS. These results showed a natural loss of antioxidant capacity of saliva after RT  and BC wThis body of evidence was brought up for discussion with regard to the most opportune time to start BC therapy, concomitantly or after RT. The model of free radicals and peroxides that bind to acinar cell membrane receptors, blocking the activation of the entire intracellular protein signaling cascade in salivary glands , could jet al. (Miah et al.  evaluateet al.  and the In conclusion, BC therapy used as treatment of XT in patients submitted to head and neck RT, could be important in decreasing the levels of this symptom, but not effective as prophylactic BC therapy. The substantial increase in Amylase concentration suggests that BC stimulates the remnant parotid cells that were not affected by RT.


Smoking is a risk factor for several diseases. Physicians are role models for their patients. Physicians who smoke underestimate the health risks of smoking and may be less likely to offer advice to help their patients to quit. The aim of this study was to: provide an overview of smoking behaviour among Estonian physicians; assess the relationship between smoking and ischaemic heart disease (IHD), chronic bronchitis (CB), and lung emphysema (LE); and estimate fractions of prevalences of the three diseases attributable to smoking.n = 5666) in Estonia in 2014. Prevalence of smoking and relative risks for IHD, CB and LE as well as the risks of IHD, CB and LE attributable to smoking were calculated by age and sex. Post-stratification was used to compensate non-response.Self-administered questionnaires were sent to practising physicians  among men and 5.0% (95% CI 4.4–5.6%) among women. Mean duration of smoking among male and female daily smokers was 28.6 (95% CI 26.1–31.1) and 28.6 (95% CI 27.1–30.2) years. Compared to lifelong non-smokers, the age-adjusted risk for IHD was 1.29 times (95% CI 0.88–1.89) higher for men, but 1.69 times (95% CI 1.17–2.40) lower for all women who have ever smoked. The risk for CB was 2.29 (95% CI 1.30–4.03) times higher for smokers among men and, 1.32 (95% CI 0.95–1.82) among women; the risk ratio for LE was 4.92 (95% CI 1.14–21.1) among men and 2.45 (95% CI 0.63–9.52) among women. The smoking-attributable risk for IHD was 3.2% (95% CI 2.3–4.1%) among men and − 0.1% (95% CI -0.7–0.4%) among women; for CB 6.9% (95% CI 6.0–7.8%) and 4.2% (95% CI 3.5–4.8%); and for LE 18.8% (95% CI 17.0–22.5%) and 22.6% (95% CI 18.5–26.9%), respectively.Prevalence of daily smoking was relatively low among Estonian physicians . The risk attributable to smoking was higher for LE and CB than for IHD.The online version of this article (10.1186/s12889-018-5105-6) contains supplementary material, which is available to authorized users. Tobacco smoking is a major risk factor for cardiovascular diseases –3, incluPhysicians are widely regarded as health behaviour role models –11. At tPrevious reports have shown that smoking prevalence among physicians in high income countries  has decreased –18. The Smoking prevalence in the total population in developed countries (including Estonia) has decreased during recent decades as well . In EstoMany studies have shown that smoking increases the risk of heart and lung diseases –6. In 20To our knowledge no-one has estimated the proportions of prevalence of IHD, CB and LE attributable to smoking before, neither among physicians nor among the general population in Estonia. The aim of this paper was to provide an overview of smoking behaviour among Estonian physicians; assess the relationship between smoking and IHD, CB, and LE; and estimate fractions of prevalences of the three diseases attributable to smoking.n = 5666). The four-page questionnaire was similar to that which was used in the previous 2002 study on smoking among Estonian physicians, which had been adapted from a questionnaire originally developed by the World Health Organization [We conducted a cross-sectional study with total sampling, the conduct of which is described in detail elsewhere . All phynization . A reminThe participants were asked if they had ever been smoking regularly at least for a year; their age of taking up smoking; and their current smoking behaviour. These questions allowed to define four categories: never smokers (who answered ‘no’ to the question asking about ever smoking regularly), ex-smokers (who answered ‘yes’ to the question asking about ever smoking regularly and ‘no’ to the question regarding current smoking), occasional smokers (who answered ‘yes’ to the question regarding current smoking and ‘no’ to the question regarding daily current smoking), daily smokers (who answered ‘yes’ to the question asking about daily current smoking).Daily smokers were asked the number of cigarettes they smoked each day ; therefore, only the proportions of daily smokers who smoke more than a pack (20 cigarettes) in a day is described and this information is not considered in further analysis.A multiple-choice question was asked about currently having IHD, CB, or LE; refusal to answer was an additional option. Anyone who did not choose from any of the options  was considered to be a person who does not have any of the afflictions.P is the proportion of diseased among individuals with exposure level k (0 = never smoker) and confounder level s, P(Ek| Cs) is the prevalence of exposure level k among individuals with confounder level s, P(Cs) is the prevalence of confounder level s, and P(D) is the prevalence of disease [ARk denotes AR specific to exposure level k and wk equals the proportion of cases in level k [To reduce bias caused by differential response rate (i.e. younger people and men being under-represented) post-stratification weights (based on sex and 5-year age groups) were used to compensate unit non-response (non-returned or unfilled questionnaires) . Unadjus disease . The ove level k . To acco level k . Age wasEpiInfo 3.5.3  was usedIn total, 2939 practising physicians (535 men and 2404 women) participated in this study. The crude response rate was 52%, while the corrected response rate  was 53%. About four fifths  of the respondents lived in cities or towns.The age of the study participants was between 24 and 86. Men (18% in the sample vs. 23% in the population) as well as younger physicians (mean age 51.7 years in the sample vs. 51.2 in the population) were slightly under-represented in the sample. The distribution of physicians by age groups and sex in the target population and the proportions participating in the study in each age-sex group is given in Table Current smokers  constituted 8.4% (95% CI 7.6–9.1%) of Estonian physicians. The prevalence of daily smoking was highest in the age group of 51–60 both among men and women Table . Among mIn general, smoking behaviour by age groups was somewhat different between men and women Table . Among pIn general, men had longer history of smoking than women Table . Male exn = 2177), there were 122 IHD cases (77 among never smokers), 106 CB (55 among never smokers), and 11 LE cases (3 among never smokers).There were 762 physicians (25.9% of the sample) who did not wish to respond to the diseases-related questions. Among the rest ; 4.5% (95% CI 3.8–5.2%) among never, 7.0% (95% CI 5.3–8.6%) among ex-, 7.4% (95% 0.6–14.2%) among occasional, and 7.0 (95% CI 3.9–10.2%) among daily smokers. Overall CB prevalence was 4.8% (95% CI 4.2–5.4%); 3.4% (95% CI 2.8–4.0%) among never, 5.9% (95% CI 4.4–7.4%) among ex-, 3.8% (95% CI 0.0–8.9%) among occasional, and 17.7% (95% CI 12.8–22.6%) among daily smokers. Overall LE prevalence was 0.6% (95% CI 0.4–0.8%); 0.2% (95% CI 0.0–0.3%) among never, 1.6% (95% CI 0.8–2.5%) among ex-, 0% (95% CI 0.0–0.0%) among occasional, and 1.2% (95% CI 0.0–2.8%) among daily smokers.There was a clear trend of increasing prevalence of IHD and CB by age groups, the trend for LE prevalence was less visible due to a small number of cases Fig. . IllustrRelative risks for the three diseases comparing smokers to non-smokers were higher among men than among women. Compared to lifelong non-smokers, the age-adjusted risk for IHD was 1.29 times (95% CI 0.88–1.89) higher for all men who have ever smoked, but 1.69 times (95% CI 1.17–2.40) lower for all women who have ever smoked. Age-adjusted risk ratio for CB comparing ever smokers to never smokers was 2.29 (95% CI 1.30–4.03) among men and 1.32 (95% CI 0.95–1.82) among women; respective risk ratios for LE were 4.92 (95% CI 1.14–21.1) and 2.45 (95% CI 0.63–9.52). Age-adjusted RR having any of the three conditions comparing those that have smoked to never smokers was 1.66 (95% CI 1.23–2.25) for men and 0.89 (95% CI 0.70–1.12) for women.There was a clear association between the number of years smoked and the risk of IHD or CB, especially among men Table . CompareAfter adjusting for age and years smoked, the prevalence of LE attributable to smoking was 19% among men and 23% among women, while the attributable prevalences for IHD and CB were much lower  Table . While tThis study focused on smoking behaviour and the relationship between smoking and IHD, CB, and LE among Estonian physicians. The years smoked were associated with the risk for these three diseases. The risk attributable to smoking was higher for pulmonary diseases than for ischaemic heart disease.In Estonia 53% of male and 75% of female physicians had never smoked, while 12% of male and 5% of female physicians smoked daily in 2014. Smoking behaviour among younger (up to 40 years old) male and female physicians were more similar to each other than among physicians older than 40 years. Similar phenomenon has also been observed in other studies and has been associated with changing socio-economic circumstances . CompareOur results support the hypothesis that the decline of smoking among the general population follows the decline of smoking among physicians , 25. WhiInterestingly, in the current study women aged between 41 and 50 years who smoked occasionally had been smoking longer time (17.9 years in average) than women aged between 51 and 60 (11.3 years). In addition to recall bias, this difference, although statistically not significant at the 0.05 significance level (results omitted), can be partially explained by the average age they started smoking. We found that women in the age group of 41–50 years started smoking younger than women in the age group of 51–60. However, the time between starting smoking and the study conduct was generally longer than the number of years smoked that the subjects reported. This indicates that the subjects had had smoke-free periods. Hence, it is possible that women in the age group of 51–60 years had had more and/or longer breaks in smoking, although these data were not collected in our study.Although the prevalence of IHD and CB was similar among male and female non-smokers , this prevalence was much higher among formerly or currently smoking men, compared to women of the same age and smoking class. This can be partially explained by the number of cigarettes smoked daily, which is higher among men in many countries . AlthougUnsurprisingly, there was a clear association between the risk of smoking-related diseases and years smoked: age-adjusted risk for the IHD and CB was higher among those men and women who had smoked longer. These results are consistent with worldwide literature , 2. AlthIn our study, the effect of smoking was clearest in the prevalence of CB. It was reported that for current smokers in the United States, CB was the most prevalent condition, followed by LE . While tIt has been indirectly estimated that in 2015 in Estonia, 8% of deaths caused by IHD among women and 22% among men in general population were associated with tobacco smoke (corresponding proportions being similar for years of life lost and years of life lived with a disability) . In our One might assume that due to cleaner working environment of physicians compared to that of an average citizen’s, among physicians other risk factors  would not contribute to the risk of pulmonary diseases as much as smoking would do. However, 80% of deaths caused by COPD among men and 41% among women were associated with tobacco smoke in the general population (and these proportions were similar for other measures of burden of disease)  while inConsisting of working physicians, the study population can be considered relatively homogeneous, which reduces the effect of possible confounders . Almost half of the target population participated in the study, resulting in more precise estimates. Our sample had a definite frame  with the information on the age and sex of physicians which allowed us to compensate for non-response by post-stratification.There were some physicians who contacted the study team asking whether they should participate if they are non-smokers. Therefore, non-smokers might be under-represented in the final sample. On the other hand, it is plausible that subjects who behave in a socially less desirable way (e.g. smoke daily) were less inclined to participate in this study. Physicians are perceived as most knowledgeable about the devastating effects of smoking; therefore, they may be prone to self-deception or understatement. However, the anonymity of the questionnaire supports the possibility of the responses being true. As smoking behaviour as well as health are associated with age and sex, we believe that post-stratification helped us to reduce that bias.The questionnaire was self-administered, which may have introduced some information bias. For example, the number of years smoked might have been reported imprecisely. Considering the IHD, CB and LE, however, physicians probably have better knowledge about their health condition compared to a layman, which makes the data on self-reported health condition reasonably reliable. Nevertheless, a considerable number of physicians chose not to reveal data on having the three diseases we studied. In addition, we were not able to make certain that those who did not choose from any of the multiple choices regarding smoking-related health condition (including the option to refuse to answer) were free from those conditions. Therefore, the prevalence of IHD, CB, and LE might be underestimated. Hence it is plausible that the attributable risk estimates are underestimates as well.Many factors may have influenced the response rate . For exaThe cross-sectional design of this study was suitable for estimating prevalences. Although we do not know the timing of events , which inhibits causal interpretation of attributable risks, it has been observed that people more often quit than start smoking after getting pulmonary  or cardiPrevalence of daily smoking was relatively low among Estonian physicians being twice lower among female physicians compared to male. Risk attributable to smoking was higher for lung emphysema and chronic bronchitis than for ischaemic heart disease, hence communicating the information about the negative effects of smoking to the people who already are at greater risk for pulmonary diseases is strongly advised.Tobacco control policies should focus on increasing smokers’ willingness to quit smoking and providing the necessary support and therapies. This would increase the likelihood of successful smoking cessation among physicians which would have major benefits to health of the general population. Further studies are required to continue monitoring the smoking behaviour among Estonian physicians.


Individuals living at moderate altitudes (up to about 2000 m) were shown to have lower mortality from coronary artery disease (CAD) and stroke (−22% and −12% per 1000 m) . HoweverAltitude-dependent mortality from CAD, male colorectal cancer and female breast cancer from 2003 to 2012 in Austria has been evaluated based on data from the Austrian Mortality Registries (Statistik Austria) . Since tThe general life expectancy, e.g. in 2009, increased from low altitude <251 m) to higher altitudes (1001 to about 2000 m) by about 2 years, in males from 76.7 to 79.1 years and in females from 82.1 to 84.1 years [1 m to hiThe lower mortality from CAD at moderate altitudes is in close agreement with that reported from Switzerland . Reduced


The vascular bundle especially in the peduncle is one of crucial limiting factors of rice yield, and it determines how plants efficiently transport photosynthetic products, mineral nutrients and water from leaf and root to panicle. However, the genetic base of rice vascular bundle related traits in the peduncle still remains unknown.P < 1.0 × 10− 4. Combined determining linkage disequilibrium (LD) blocks associated with significant SNPs and haplotype analyses allowed us to shortlist six candidate genes for four important QTL regions affecting the peduncle vascular bundle traits, including one cloned gene (NAL1) and three newly identified QTL . Further the most likely candidate genes for each important QTL were also discussed based on functional annotation.The 423 panel showed substantial natural variations of peduncle vascular bundle. In total, 48 quantitative trait loci/locus (QTL) affecting the eight traits were identified throughout the genome by applying a significance threshold of NAL1 and the three newly identified QTL  were analyzed. The results provided valuable information for future functional characterization and rice breeding for high yield through optimizing transportation efficiency of photosynthetic products by marker-assisted selection.Genetic base on peduncle vascular bundle related traits in rice was systematically dissected, and most likely candidate genes of the known gene The online version of this article (10.1186/s12284-018-0204-7) contains supplementary material, which is available to authorized users. Oryza sativa L.) is one of the most important cereal crops and a staple food for more than one-half of the world’s population. In retrospect of rice breeding history, good harmony of source, sink and translocation capacity (i.e. flow) of assimilates plays an important role in improvement of rice yield potential  than japonica varieties, though there is no significant difference in the number of small vascular bundle (SVN) between them. The exploitation of the great heterosis that exists in the inter-subspecific crosses between indica and japonica rice has long been considered as a promising way to increase the yield potential. It is therefore of importance to study the genetic basis of peduncle vascular bundle to provide useful information for the genetic improvement of rice yield potential using heterosis between indica and japonica.The vascular bundle systems in plants play a significant role in delivering water and nutrients as well as other substances needed for growth and defense  and phloem area of small vascular bundle (SVPA) showed skewed distributions in 2016 Fig. . The panFor the 26,097 high quality SNPs, the number of markers per chromosome ranged from 1600 on chromosome 9 to 3101 on chromosome 1. The size of chromosome varied from 22.93 Mb for chromosome 9 to 43.25 Mb for chromosome 1. The whole genome size was 372.50 Mb. The average marker spacing was 14.27 kb with spacing ranging from 12.68 kb for chromosome 10 to 15.50 kb for chromosome 4  can be reserved as informative Fig. . The scoA total of 48 different QTL for all traits were identified in 2015 and 2016, ranging from two QTL for SVPA to 10 QTL for LVPA. Among them, 23 (37) QTL were detected in 2015 (2016) and 12 QTL were commonly detected in two years  were only detected in 2016, which were accounted for phenotypic variance from 3.5% to 3.9%. Three QTL, qLVA4.1, qLVA8 and qLVA11, were detected in both years and explained the average phenotypic variance of 2.6%, 3.1% and 3.2%, respectively , seven QTL were detected on chromosomes 1, 3, 4, 6, 8 and 11. The qLVPA8.2, qLVPA8.3 and qLVPA11) were detected in 2015, and accounted for 3.2% to 3.6% of phenotypic variance. Five QTL  were detected in 2016 and accounted for phenotypic variance from 3.4% to 3.7%. Another two QTL, qLVPA4.1 and qLVPA8.4 were commonly detected in the two years, and explained the average phenotypic variance 3.5% and 3.3%, respectively , seven QTL were detected on chromosomes 1, 5, 6, 8, and 11. Among them, only qSVN1, qSVN2 and qSVN5.2) detected in 2016 and two (qSVN5.1 and qSVN7) in the two years. The first three QTL accounted for phenotypic variance from 3.5% to 3.6% while the latter two QTL explained the average phenotypic variance of 4.3% and 3.9%, respectively  were detected in 2015, and accounted for 3.7% and 3.6% of phenotypic variance, respectively. The other four QTL  were detected in 2016, and accounted for 3.4% to 3.8% of phenotypic variance , a total of six QTL were detected on chromosomes 2, 8, 11, and 12. Two QTL  were detected in 2015 and accounted for 4.4% and 4.5% of phenotypic variance, respectively. Another two QTL (qSVXA2 and qSVXA8) were detected in 2016 and explained 3.5% and 3.4% of phenotypic variance, respectively , four QTL were detected on chromosomes 2, 8, 9 and 11. Of them, two QTL  on chromosome 6  of 3.43 and 3.08 in 2015 and 2016, respectively. Again, SNPs with –log10 (P) above the threshold (2.43 in 2015 and 2.08 in 2016) were found to locate in one gene, Os06g0685700  in japonica, though there was no significant difference for LVN between different haplotypes in indica accessions  of 3.73 (3.47) in 2015 (2016) for LVA, and 3.49 (3.21) in 2015 (2016) for LVPA. Two genes harboring SNPs with –log10 (P) larger than the thresholds were identified, including Os04g0613000 and Os04g0615000  in whole population . Of the two genes, Os04g0615000 is identical to NAL1 (NARROW LEAF1), the gene regulating the development of vascular bundle in previously reported  on chromosome 4 harboring 4.1 Fig. , and 303000 Fig. . Highly ion Fig. –d. Of thGTA Fig. –d.Fig. 4QSVN7 was fine-mapped in the region of 29.46–29.67 Mb (210 kb) on chromosome 7  of 3.57 and 3.34 in 2015 and 2016, respectively. SNPs with –log10 (P) above the thresholds were located in the two candidate genes, Os07g0695100 and Os07g0694700   of 3.56 for qSVA8.1 and 3.50 for qSVXA8 in 2016. Two genes harboring the SNPs with –log10 (P) larger than the threshold  were identified, including Os08g0137100 and Os08g0137250  Fig. , and 277250 Fig. . Signifi250 Fig. –d. HowevIndica and japonica are the two major types of Asian cultivated rice (Oryza sativa L.). There are significant differences between them in many morphological and physiological traits associated with the processes of indica-japonica differentiation  than japonica (nearly1.0) (Fukuyama and Takayama indica (averaged 21 in 2015 and 19.9 in 2016) was also significantly higher than those of japonica (averaged 16.1 in 2015 and 15.5 in 2016) , resulting almost in same quantity of LVN in the peduncle and number of PRBs. On the other hand, in indica-type some large vascular bundles are directly connected to the secondary rachis branches due to surplus large vascular bundles  was detected, containing two candidate genes. One of them was NAL1 (Os04g0615000) regulating the development of vascular bundle which may be involved in polar auxin transport  in the third exon exerted a critical function on determining panicles per plant, spikelet numbers per panicle, flag leaf width and area of large vascular bundle in the peduncle.In the region of 31.07–31.26 Mb on chromosome 4, a QTL cluster (qLVN6 and qSVN7) were detected in both two years. The qLVN6 affecting LVN was identified in the region of 28.55–28.92 Mb on chromosome 6.The only candidate gene for qLVN6 was OsARF18 (Os06g0685700), a similar to auxin response factor gene. The deregulation of the OsmiR160 target gene OsARF18 leads to rice abnormal growth and development, including dwarf stature, rolled leaves, and small seeds through affecting the auxin signaling  regulating the development of vascular bundle played its role in leaf morphogenesis by regulating polar auxin transport, and plays a regulatory role in the development of plant type in rice  is considered as a possible candidate gene of qLVN6. Transgenic experiments are under way to verify the functionalities of the candidate genes. The only candidate gene for qSVN7, Os07g0695100 (Ghd7.1) was a major QTL with pleiotropic effects on grain number per panicle, plant height, and heading date in rice (Oryza sativa L.) in previously report  belongs to the PcG protein family and is the most likely candidate gene. Compared to wild-type, the number of large and small vascular bundles decreased in second internode of osfie2–1 stem, as well as cell number and cell size in spikelet hulls  was detected in both two years affecting LVN. According to gene function annotation, Os06g0685700, a similar to auxin response factor gene is considered as the most likely candidate gene of qLVN6. Haplotype analysis revealed that significant differences for LVN were between different haplotypes at the gene in japonica accessions. Two tropical japonica varieties, PLUS (averaged 20.4 in 2015 and 23.5 in 2016) and ITA 221 (averaged 21.7 in 2015 and 23.7 in 2016) with more LVNs were found in this panel. Haplotype TTGAAG of the Os06g0685700 from the two japonica accessions exhibited additive effect for increased number of large vascular bundles in peduncle in japonica and this favorable QTL allele would be introgressed into indica and other japonica varieties with superior agronomic traits for improved large vascular bundle by marker-assisted selection (MAS). Specifically, for example, hybrid between indica and japonica holds large panicle with more primary rachis branches especially secondary rachis branches but its grain yield is seriously limited by insufficient grain filling due to disharmony of source, sink and flow of assimilates. So, it is possible to improve grain filling of hybrid between two subspecies by reasonably deploying favorable alleles of QTL for peduncle vascular bundle related traits in rice as indicated in this study.Our results suggested that in the region of 28.55–28.92 Mb on chromosome 6, a QTL (NAL1), were identified by determining linkage disequilibrium blocks associated with significant SNPs, and haplotype analyses. In addition, the most likely candidate genes for three new QTL  were identified based on functional annotation. The results will enhance our knowledge of the genetic basis of vascular bundle traits in rice, facilitate exploring the molecular mechanisms underlying the traits, and provide valuable information for improving rice vascular bundle system by MAS breeding.We identified 48 QTL for eight peduncle vascular bundle related traits via GWAS. A total of six candidate genes of four important QTL regions, including the cloned gene (indica (301), temperate japonica (13), tropical japonica (57), admixed japonica (9), admixed type (17), aus/boro (16), and basmati/sadri (10)  during Dec 2014–April 2015 and Dec 2015–April 2016 and each accession was planted in two rows with 10 individuals each row at a spacing of 25 cm between rows and 17 cm between plants with two replications for each accession. The field management followed the farmers’ standard management practices. In order to minimize flowering time effects experiment-wise, batch sampling were performed based on heading date of each accession. At full heading stage, five uniform plants in the middle of each plot were selected. The transverse section of stem were made at uniformly 2 cm above the neck-panicle node and kept in formalin-acetic-alcohol (FAA) fixative solution. After safranin O staining, vascular bundle related traits in the peduncle, including the number of large vascular bundle (LVN), the total area of large vascular bundle , the phloem area of large vascular bundle , the xylem area of large vascular bundle , the number of small vascular bundle (SVN), the total area of small vascular bundle , the phloem area of small vascular bundle  and the xylem area of small vascular bundle   and population structure (Q) were applied to infer population structure. For the 26,097 SNP, we further removed SNP loci with missing rate over 10% and MAF less than 0.10. Then, 6601 evenly distributed SNPs with average marker spacing around 50 kb were sampled to calculate population structure (Q). A model based Bayesian clustering analysis method implemented in STRUCTURE software version 2.3.4 , PCA + K, was used in the association analysis. And we performed the study by the software GAPIT. The MLM includes both fixed and random effects. Including individuals as random effects gave an MLM the ability to incorporate information about relationships among individuals. This information about relationships was conveyed through the KI matrix, which was used in an MLM as the variance-covariance matrix between the individuals. Then a genetic marker-based KI matrix was used jointly with PCA  of the peak SNP of the detected QTL minus 1  consistently identified in both two years; (2) affecting more than one trait; and/or (3) close to previously reported cloned genes or fine mapped QTL. The following five steps were conducted to identify candidate genes for important QTL identified. Firstly, the LD block was analyzed using the software “Haploview v4.2” Additional file 2:Table S1. List of the 423 accessions including country of origin, subpopulation , population structure (Q), PC score, vascular bundle related traits measured in 2015 and 2016, and heading date measured in 2016. (XLSX 115 kb)Additional file 3:Figure S2. Genome-wide association results for 8 vascular bundle related traits. Manhattan plots (left) and quantile-quantile plots (right) associated with LVN (a), LVA (b), LVPA (c), LVXA (d), SVN (e), SVA (f), SVPA (g), and SVXA (h) in 423 accessions in 2015 and 2016. For the Manhattan plots, −log10P-values from a genome-wide scan were plotted against the position of the SNPs on each of 12 chromosomes and the horizontal grey dashed lines show the suggestive threshold (P = 1.0 × 10− 4). For the quantile-quantile plots, the horizontal axes indicate the –log10 -transformed expected P values, and the vertical axes indicate the –log10-transformed observed P-values. Arrows indicate QTL overlapping with the published QTL. (PPT 1286 kb)Additional file 4:Figure S3. Comparisons of eight vascular bundle traits between indica and japonica subpopulations. Blue and orange bar indicate indica and japonica, respectively. All data are presented as the mean ± SD. *, P < 0.05 and ***, P < 0.001. (PPT 190 kb)Additional file 5:Table S2. Haplotype analysis of the targeted genes related to qSVA8.1 and qSVXA8 in the whole population, indica and japonica subpopulations, respectively. The letters  indicate multiple comparison results at the significant level 0.05. (XLSX 10 kb)Additional file 6:Figure S4. Comparison of LVA and LVPA between A and G alleles located in the third exon of Os04g0615000 (NAL1) gene. The letters on histogram  indicate multiple comparisons result at the significant level 0.05. The value on the histogram is the number of individuals of each allele. (PPT 217 kb)Additional file 7:Figure S5. Comparisons of heading date, grain number per panicle and plant height among different haplotypes of Ghd7.1 gene in 2016 Sanya. The letters on histogram  indicate multiple comparison results at the significant level 0.05. The value on the histogram is the number of individuals of each haplotype. (PPT 218 kb)Additional file 8:Figure S6. Cross-sections of large and small vascular bundle in peduncle stained with safranin O staining. P, phloem; XP, xylem parenchyma; PX, protoxylem element; MX, metaxylem element; PXL, protoxylem lacuna. (PPT 699 kb)


Our aim was to review our management of inverted papilloma (IP), perform a recurrence analysis, and review the literature.A retrospective analysis of 247 patients treated for an IP. Patients were grouped according to surgical approach, tumor presentation  and Krouse-stage.p = 0.017) of the patients who underwent endoscopic, external and combined surgery, respectively. Recurrences occurred more often in residual than primary IP . Primary endoscopic surgery had a recurrence rate of 12.5%, which was comparable to the recent literature .Recurrence was observed in 20.3%, 28.6% and 35.1% (The relatively high number of recurrences in this cohort is explained by the long follow-up and previous (incomplete) surgery in 61.5% of the cases. The inferior outcome of residual IP underscores the importance of having a low threshold for preoperative biopsy in unilateral and atypical sinonasal disease. Inverted papilloma (IP) is a benign tumor of the sinonasal cavities. It was first described by Ward more than 150 years ago as a follicular tumor involving the nasal bones . Since tThe incidence of IP ranges from 0.2 to 0.6 people diagnosed per 100,000 per year. The most frequently reported complaints are similar to those of sinonasal polyps: unilateral nasal obstruction and rhinorrhea. IP is most commonly diagnosed in the fifth and sixth decade of life and has a predilection for males with a ratio of 3:1 . The exaThe standard treatment has always been surgery aimed at complete removal of the tumor. Its association with malignancies in 5–15% is one of the distinct characteristics of IP that endorses surgical treatment . Other iThe aim of this study was to analyze the developments in our management of IP over the last three decades, in particular with regard to the recurrence rates and outcomes of treatment. All surgical approaches were reviewed, with an emphasis on endoscopic surgery. Whether the presentation of the tumor  before surgery in our clinic would affect the recurrence rate also had our interest. Finally, a literature review of IP cohort studies was performed to compare with our surgical outcomes and recurrence rates.The Ethics Committee of the Erasmus Medical Center, a tertiary referral medical center, stated that ethical permission was not required for this retrospective study.We included 323 IP patients, of which 247 were included in the recurrence analysis, between January 1983 and December 2012. All patients were obtained from PALGA, a Dutch nationwide network and registry of histo- and cytopathology. All cases received surgical treatment, had a preoperative histopathological proven diagnosis of IP, and complete clinical information. Clinical data was assessed using the electronic medical records  and paper charts.The IP was classified as a primary when no prior surgery was performed and diagnosis was confirmed by a simple biopsy. Patients with previous surgery were divided into two groups: residual and recurrent IP. Residual IP were defined as those who underwent functional endoscopic surgery for reasons other than IP, which was deemed as inadequate tumor surgery. Inverted papilloma diagnosis is this group was unexpected at postoperative histopathological examination. Recurrent IP were defined as those who underwent adequate tumor surgery in a different, non-academic hospital with the preoperative suspicion or diagnosis of IP. These patients were referred to us for revision surgery after diagnosis of a recurrence.All patients underwent surgery by experienced head and neck surgeons. Surgical treatment was divided into three groups: endoscopic surgery , external surgery  and combined approaches . The extent of surgery and approach were chosen based on the perceived origin and extent of the IP. In the endoscopic group, we mainly performed a medial maxillectomy, including (at least the posterior two thirds of) the inferior turbinate and an ethmoidectomy. We opted for a radical ethmoidectomy, including middle turbinate and opening of the frontal recess, for tumors limited to the ethmoid and/or frontal recess. For the external approach, we mainly performed a classic Denker . The combined approach was applied to maxillary tumors originating lateral to the infraorbital nerve. A medial maxillectomy was performed in all cases with the exception of tumors limited to only the frontal sinus or sphenoid. Complications after surgery were classified according to the Clavien-Dindo Classification of Surgical Complications Table  10]. Al. Al10]. A literature search was performed of EMBASE  using the key term ‘inverted papilloma’. All IP case series with a minimal follow-up of 12 months, reporting on recurrence rates per operative approach, and published in the English language were included.p < 0.05.When quantitative variables were normally distributed, the results were expressed as mean values and standard deviation (SD), otherwise median and inter quartile range (IQR). Differences between two groups were analyzed using the t-test or the Mann-Whitney U test. Qualitative data are reported as counts and frequencies, and differences between groups were analyzed using the chi-squared test or Fisher’s exact test. Multivariate logistic regression was used to investigate the association of Krouse staging, surgical approach and presentation of tumor and the risk of recurrence . Cox regThe mean age at time of diagnosis was 55.8 years (SD 13.7). The study population consisted of 245 males and 78 females . Nasal obstruction was the most frequent complaint . Other complaints were rhinorrhea , headache , epiphora  and feeling of pressure in the face or forehead . Thirty patients (9.3%) had no complaints. Preoperative radiological imaging was performed with CT-scan in 201 cases (62.2%) and with MRI in 15 cases (4.6%). Both CT and MRI were used in 62 patients (19.2%). Forty-five patients (13.9%) underwent surgery without preoperative radiological imaging. The left and right side of the sinonasal cavity were equally involved (50.2% vs. 48.3%). Five patients (1.5%) had bilateral involvement.In 121 of the cases (37.5%) the inverted papilloma was primary, in 115 cases (35.6%) residual, and in 87 cases (26.9%) recurrent. The tumors were classified as Krouse T1 to T4 in respectively 38 (11.8%), 148 (45.8%), 108 (33.4%) and 29 cases (9.0%). Twenty-eight IP were classified as T4 because of an associated malignancy and one because of extrasinonasal extension. Endoscopic surgery was performed in 107 patients (33.1%), a combined approach in 22 cases (6.8%) and an external procedure in 194 patients (60.1%).The overall percentage of perioperative complications was 14.6% (47 cases). Most complications were Clavien-Dindo grade I , such as sensibility disorders, perioperatively managed cerebrospinal fluid leakage and excessive crustae. Ten patients (21.3%), including four wound infections, had grade II complications. Most Clavien-Dindo grade III complications  were complaints of epiphora after a classical Denker procedure that required a dacrocystorhinostomy. Two patients  developed meningitis post-operatively and had to be admitted to the intensive care unit. One patient died post-operatively as a result of severe comorbidity .Thirty-one patients (9.6%) had an associated malignancy. The malignancy occurred synchronously in 28 cases (90.3%). They consisted of 25 squamous cell carcinomas (89.3%), two verrucous carcinomas (7.2%), and one undifferentiated carcinoma (3.6%). Three other cases squamous cell carcinomas developed metachronously (9.7%).Four patients (12.9%) had a carcinoma in situ. Nine patients had tumor with T stage I (29.0%) three with II (9.7%), three with III (9.7%) and 12 with IV (38.7%). Three patients (9.7%) had a regional lymph node metastasis and three patients (9.7%) a distant metastasis. Most patients (80.6%) with an associated malignancy were treated with an external approach. For patients with an associated malignancy, the 5-year overall survival was 80.6% and the 5-year disease specific survival 87.1%. Eight patients with an a associated malignancy (25.8%) developed a recurrent IP after initial treatment. The 5-year recurrence free survival rate was 77.4%. During follow-up 20 patients (64.5%) remained alive with no evidence of disease. One (3.2%) was alive with disease, eight (25.8%) died of disease, and two (6.5%) died of other cause.We included a sub selection of 247 patients cohort in our recurrence analysis. Sixty-one patient were excluded because their follow up was <2 years. Another fifteen patients with suspected residual IP were excluded because postoperative histopathologic examination did not confirm the residual IP. The median follow-up was 66.2 months (IQR 41.1–112.9). Overall recurrences occurred in 74 patients (30.0%)  and recurrent (37.5%) tumors, this percentage was higher. The distribution of Krouse stage was not significantly different in these groups (Table Seventy-nine 32.0%) cases in our recurrence analysis were treated with pure endonasal endoscopic surgery. Recurrences occurred in sixteen endoscopic cases (20.3%). Primary IP treated endoscopically recurred in three cases (12.5%), residual IP in eight cases (25.0%) and recurrent IP in 5 cases (21.7%). Four of fourteen patients (28.6%) treated with a combined approach developed a recurrence. The majority of the cases had an external procedure . They developed recurrences in 54 cases (35.1%). This is significantly higher than the endoscopic group (.0% casesp = 0.021 OR 95% CI 2.2 [1.1–4.3]). Recurrence occurred in 21 cases (30.9%) in the recurrent IP group.The risk of recurrence was significantly higher in the residual IP group than primary IP , 36 (30.5%), 25 (28.9%), and 6 (42.9%) cases.The median time to recurrence was 20.5 months (IQR 11.8–37.5). The surgical approach and the presentation of the tumor had no significant influence on the time to recurrence. Table p = 0.049). Eighteen patients (24.3%) developed a third recurrence, while six patients (8.1%) developed even more than three recurrences during follow-up.Thirty-seven (50%) of all 74 cases with a recurrence after initial surgery in our hospital developed a second recurrence after revision surgery. This occurred more often in the group of patients that underwent external surgery than the endoscopic group  respectively.Our recurrence in the endoscopic group (20.3%) was also higher than the average 11.2% (161/1433) in our review of the recent literature Table . HoweverA wide range of recurrence rates (0.0–45.0%) have been documented after revision surgery Table  20, 26–, 38–40. Many articles claim that the majority of recurrences after IP-surgery occur in the first two years , 43. ShaThe recurrence rate of residual tumors is significantly higher than primary tumors. Therefore clinicians should have a low threshold for suspecting IP and when uncertain first take a biopsy. Furthermore, given the mean time to recurrence and the rate of late recurrences a long follow-up is required in both the clinic and research.


To compare anterior chamber depth (ACD) changes after phacoemulsification surgery in patients with pseudoexfoliation syndrome (PEX) and normal patients using an anterior segment imaging method. Another aim of this study was to evaluate the effect of these changes on the accuracy of intraocular lens (IOL) power calculation and postoperative refraction. Twenty-two eyes of 22 patients with PEX and 30 eyes of 30 normal patients who underwent uneventful phacoemulsification surgery and IOL implantation were included in the study. The ACD of all patients was evaluated preoperatively and at 3 months postoperatively with the ALLEGRO Oculyzer -Scheimpflug imaging system. The postoperative mean ACD values were significantly larger than the preoperative ACD values in both groups (p<0.001 for both groups). The pre- to postoperative change in ACD was 0.46±0.3 mm in the PEX group, which was a larger change than seen in the normal patients (0.12±0.1 mm) (p=0.04). The mean absolute errors (MAE) calculated with different IOL formulas  were comparable and no statistically significant difference was observed between the two groups (p=0.21). Phacoemulsification induces more significant ACD changes in patients with PEX compared to normal patients. However, the MAE did not differ significantly between the groups. Most biometric formulas estimate ELP mathematically by using keratometric data and AL. ELP plays a key role in the accuracy of IOL power formulas.5 Thus, a difference of only 1 mm in IOL position leads to approximately 1.25 diopter (D) change in refraction.7 Therefore, correct estimation of ELP is a critical step in IOL power prediction.3Accurate intraocular lens (IOL) power calculation in cataract surgery is essential to achieve the postoperative target refraction and high patient satisfaction.Patients with pseudoexfoliation syndrome (PEX) frequently undergo phacoemulsification and IOL implantation for cataract surgery; however, according to our clinical observations, refractive outcomes for (PEX) patients are less accurate than the normal population. We thought that this may be due to difficulties in calculating the ELP arising from zonular laxity in (PEX) patients.The aim of this study was to compare the ACD changes in patients with (PEX) and normal eyes after phacoemulsification. Another aim of this study was to evaluate the effect of these changes on the postoperative refraction.A total of 52 eyes (22 eyes affected by (PEX) and 30 normal eyes) of 52 patients  who underwent uneventful phacoemulsification surgery and IOL implantation performed between May 2013 and May 2014 were enrolled in this prospective study. Patients with corneal pathology, glaucoma, uveitis, previous eye surgery or eye trauma, posterior segment pathology, diabetes, and those using topical or systemic medications that might influence anterior segment parameters were excluded from the study.In patients undergoing sequential bilateral phacoemulsification cataract surgery, we randomly selected (by coin toss) only one eye to be included in the study. Informed consent was obtained from all patients in compliance with the World Medical Association’s Declaration of Helsinki. The local institutional review board approved the protocol.One surgeon (A.A.) performed all operations under topical anesthesia. In all eyes, a 2.2 mm clear corneal incision through a temporal approach was created. Through this incision, a continuous curvilinear capsulorhexis measuring approximately 5.5 mm in diameter was performed. The hydrodissection was followed by phacoemulsification of the nucleus and cortex aspiration. The lens capsule was inflated with an ophthalmic viscosurgical device and the same foldable hydrophobic acrylic IOL  was placed in the capsular bag. The corneal wound was not sutured. There were no intraoperative or postoperative complications for any patients.8The ACDs of all patients were evaluated preoperatively and at the third month postoperatively with the ALLEGRO Oculyzer  - Scheimpflug imaging system, which is a diagnostic device based on the Pentacam HR technology, providing non-contact measurement and analysis of the complete anterior eye segment. The measurements were obtained by two blinded, independent observers (L.A. and M.A.) and averaged for analysis. All measurements were obtained under standard dim light conditions and without pupil dilation with the patient seated using a chinrest and forehead strap. Three measurements were obtained in each study eye and the mean value was used in quantitative analyses. Postoperative ACD was determined using inbuilt calipers on the Scheimpflug image  because Preoperative AL, keratometric power, and ACD were also measured using the IOL-Master . Preoperative biometric data in both groups were used in the IOL power formula to calculate the power of the implanted IOL, which was used to calculate predicted refractive spherical equivalent (SE). The power of the implanted IOL was determined using Haigis, SRK/T, Hoffer, and Holladay 1 formulas. Postoperative refractive errors were measured 3 months after cataract surgery using automatic refracto-keratometry . The mean absolute error (MAE) was defined as the average of the absolute value of the differences between the actual and predicted SE of the postoperative refractive error.Statistical analysis was performed with SPSS for Windows version 13.0 . All data were reported as means ± standard deviations (SD). Normality of continuous variables in a group was determined by Shapiro-Wilks test. The variables showed normal distribution (p>0.05). Therefore, a paired t-test, chi-square test and Mann-Whitney U-test were used to compare variables between the pre- and postoperative periods. The predictive accuracy of the formula was analyzed by comparing the MAEs. A paired t-test was used to compare the between-group difference in MAEs calculated by the Haigis, SRK/T, Hoffer, and Holladay 1 formula. A repeated-measures analysis of variance was used to determine the between-group difference. The difference in MAEs between the formulas was assessed using the Tukey multiple comparison test. A value of p<0.05 was considered statistically significant.Mean age was 68.3±7.3 years in the (PEX) group  and 67.4±5.8 years in the normal group . Preoperative refractive status was -1.42 D in (PEX) patients and -1.26 D in normal patients. There was no statistically significant difference with respect to gender and age between groups (p>0.05). Patients’ characteristics are listed in Mean IOL power was 21.21±2.1 D  in the (PEX) group and 21.70±2.2 D  in the normal group (p=0.67). The AL measured by the IOL-Master was 23.78±1.37 mm  in the (PEX) group and 23.48±0.80 mm  in the normal group (p=0.12). There was no statistically significant difference in mean keratometric values between groups (43.37±2.20 D in the (PEX) group; 43.39±1.80 D in the normal group; p=0.23).The mean preoperative ACD was 3.04±0.5 mm in the (PEX) group and 3.26±0.3 mm in normal patients (p=0.28). At postoperative month 3, the mean ACD was 3.52±0.3 mm in the (PEX) group and 3.38±0.2 mm in normal patients (p=0.35). The postoperative mean ACD values were significantly higher than the preoperative ACD values in both groups (p<0.0001 for both groups.). The difference between postoperative and preoperative ACD values was 0.46±0.3 mm in the (PEX) group, which was a greater change than in the normal patients (0.12±0.1 mm) (p=0.04).The MAEs calculated by the SRK/T, Haigis, Hoffer and Holladay 1 formulas were comparable between the 2 groups (p>0.05)  and no s10 In contrast, one recent study that analyzed age-and gender- matched patients with and without (PEX) found significantly smaller anterior segments in eyes with (PEX).11 In addition, the anterior chamber volume was found to be significantly smaller in eyes with (PEX) than in eyes without (PEX).12 In a study by Doganay et al.13 evaluating anterior segment parameters in patients with (PEX) syndrome or (PEX) glaucoma with the Pentacam-Scheimpflug imaging system, ACD in the (PEX) glaucoma group (2.49±0.39 mm) was found to be significantly lower than the control group and there was no statistically difference between the (PEX) group (2.50±0.29 mm) and the control group (2.60±0.31 mm). In our study, the preoperative ACD values in the (PEX) group (3.04 mm) were lower than the normal group (3.26 mm) but the difference was not statistically significant.Reports in the literature concerning the overall ocular dimensions of eyes with (PEX) are controversial. Earlier studies that looked at ACD in eyes with (PEX) did not detect significant shallowing of the anterior chamber in comparison with normal control eyes.14The ALLEGRO Oculyzer is an easy-to-use, non-contact tomography system that uses a Scheimpflug rotating camera for the analysis of the anterior segment. The measurements taken by the system are fast and user-independent. Scheimpflug imaging has been reported to calculate the ACD with a mean SD of 20 µm in healthy eyes.17 However, this is the first report comparing ACD changes after phacoemulsification surgery in (PEX) patients and normal patients.Significant changes in ACD measurements obtained by the Pentacam rotating Scheimpflug camera have been reported following phacoemulsification cataract surgery.15 demonstrated significant deepening of the anterior chamber using a Pentacam rotating Scheimpflug camera in healthy eyes. The mean preoperative ACD was 3.0±0.8 mm and the mean postoperative ACD was 3.9±0.9 mm. Similarly, the difference in ACD measured preoperatively and postoperatively was significant in a study by Doganay et al.;16 who reported a mean preoperative ACD of 2.79±0.42 mm and mean postoperative ACD of 4.63±0.57 mm. The differences between the preoperative and postoperative ACD values in both of these studies were greater than those in our study. The refractive state of the patients is not mentioned by Ucakhan et al.15 or Doganay et al.16; both groups also used the Pentacam but on slightly younger patients  than in our study. Dooley et al.17 observed a significant increase in ACD after uneventful phacoemulsification cataract surgery in patients who had a tendency towards hypermetropia preoperatively . It has been shown that hypermetropes exhibit more dramatic changes in anterior segment parameters after cataract surgery.18 In our study, the preoperative refractive status was -1.26 D in normal patients and -1.42 D in (PEX) patients. Mean increase in the ACD value  group) observed in our study was lower than those reported by previous authors.17Ucakhan et al.7 Therefore, the amount of increase in the ACD postoperatively can affect the ELP and the accuracy of IOL power calculations. In this study, preoperative and postoperative ACD and MAE were evaluated and compared between (PEX) and normal groups. To our knowledge, this is the first study to evaluate the ACD and MAE following phacoemulsification surgery in eyes with (PEX). We observed that the increase in ACD values were higher in patients with (PEX) than the normal group. We thought that this difference might affect the ELP position and planned post-surgical refraction. However, the MAE calculated using different IOL calculation formulas did not differ significantly between the groups.Recently developed biometric formulas  use preoperatively measured ACD to predict ELP.19,20 It has long been known how significant ELP is in calculation of IOL power formulas.Ethics Committee Approval: KA 15-24. Informed Consent: Obtained.Peer-review: Externally peer-reviewed.


To evaluate the results of symmetric and asymmetric surgery and responses to surgical amounts in patients with infantile esotropia.The records of patients with infantile esotropia who underwent bilateral medial rectus recession (symmetric surgery) and unilateral medial rectus recession with lateral rectus resection (asymmetric surgery) were analyzed. The results of the cases with symmetric (group 1) and asymmetric (group 2), successful (group 3) and failed (group 4) surgeries were compared, and responses to the amount of surgery were investigated.There were no significant differences between group 1 (n=71) and group 2 (n=13) cases in terms of gender, refraction, preoperative distance deviation, anisometropia and postoperative deviation angles, binocular vision, surgical success or follow-up period (p>0.05). The rate of amblyopia, near deviation and amount of surgery were higher in group 2 cases (p<0.05). Between group 3 (n=64) and group 4 subjects (n=20), no significant differences were detected in terms of gender, surgical age, refraction, amblyopia, anisometropia, preoperative deviation angles, the number of symmetric and asymmetric surgeries, the amount of surgery, or postoperative binocular vision (p>0.05). The average postoperative follow-up period was 15.41±19.93 months  in group 3 cases and 40.45±40.06 months  in group 4 cases (p=0.000). No significant difference was detected in the amount of deviation corrected per 1 mm of surgical procedure between the successful cases in the symmetric and asymmetric groups (p>0.05).Symmetric or asymmetric surgery may be preferable in patients with infantile esotropia according to the clinical features. It is necessary for every clinic to review its own dose-response results. Surgery is performed according to angle of deviation, vision level, presence of alternation and ocular motility. The most common surgical intervention is bilateral medial rectus recession (symmetric surgery). Other surgical options for infantile esotropia include medial rectus recession plus lateral rectus resection in the same eye (asymmetric surgery) and surgeries that include three or four muscles. Outcomes vary depending on the surgical procedure as well as its application and patients’ clinical characteristics, and the same surgical dose does not always yield the same results in all patients.With this study, we aimed to compare the outcomes of symmetric and asymmetric surgery in infantile esotropia and report dose-response effects observed in our clinic.This retrospective study was conducted in the Strabismus and Neuroophthalmology department of our clinic between January 2000 and August 2013; in accordance with the principles of the Helsinki Declaration, written informed consent was obtained from all participants or their legal guardians.Infantile esotropia patients with less than 60 prism diopters (PD) deviation who underwent symmetric and asymmetric surgery and were followed for at least six months postoperatively were included in the study. Patients with organic pathology, nystagmus, alphabet patterns, vertical deviation, inferior oblique hyperfunction (>1), paralytic or restrictive strabismus, mental disability, neurologic pathology, hypermetropia ≥4.00 diopters (D), history of previous ocular surgery, and those under 1 year or over 18 years old were excluded from the study. Pre- and postoperative examination findings and surgical procedure were recorded.Refraction values were determined by autorefractometer (Topcon KR-8100) or skiascopy 45 minutes after instilling cyclopentolate hydrochloride  twice with a 5-minute interval, then converted to spherical equivalent . Fundus examination was performed with direct or indirect ophthalmoscope before the induced cycloplegic effect had subsided. Best corrected visual acuity (BCVA) was assessed by Snellen chart with letters or symbols and recorded in decimal form.Amblyopia was defined as visual acuity of 0.8 or lower and two or more lines difference in visual acuity between eyes. Anisometropia was defined as at least 1.00 D difference in refraction between eyes. Treatment was initiated preoperatively in patients with amblyopia and refractive error, and was continued postoperatively when necessary.After correction of the refraction errors, near and distance deviation angles were measured with an accomodation target by either prism cover test or Krimsky test according to patient compliance and were recorded as PD. Eye movement in the nine cardinal gaze positions was examined, and the binocular vision (BV) function of communicative patients was assessed by Titmus and Worth 4 dot tests. Determination of BV was based on stereopsis of 100 seconds of arc or more and the presence of fusion.Based on each patient’s age and compliance, surgery was performed with topical (n=2), local retrobulbar (n=5) or general (n=77) anesthesia. Surgical technique was chosen according to patients’ clinical characteristics. Symmetric surgery was favored for patients who responded to amblyopia treatment and exhibited alternation, whereas asymmetric surgery was preferred for patients who had large deviation angles, did not show alternation, had low vision and were older. Postoperative esotropia of 10 PD was the goal for all patients; success was defined as a final deviation angle of ≤10 PD.The conjunctiva was opened at the limbus and the check ligaments and intermuscular membranes were cut for both recessions and resections. Recession and resection amounts were based on the recommendations of Wright3 and adjusted based on our clinical experience. Double-needle 6/0 polyglactin was used in the sclera and 8/0 polyglactin was used in the conjunctiva. Patients were examined on the first postoperative day and discharged; steroid and antibiotic eye drops were used four times daily for five days. Patients were monitored in follow-up appointments at intervals determined by their clinical status.Patients were classified as symmetric (group 1) or asymmetric (group 2) according to surgical technique, and successful (group 3) or unsuccessful (group 4) based on postoperative outcome. To obtain dose-response results, patients considered successful after a follow-up period of at least six months were evaluated in two subgroups, symmetric surgeries (group 3a) and asymmetric surgeries (group 3b).The dose-response effects, or the amount of deviation correction for each millimeter (mm) of surgery done, were calculated by dividing the difference between preoperative and postoperative deviation angle values by the total recession and recession/resection length in mm.In addition to dose-response effect, factors such as age at surgery, refraction values, visual acuity, anisometropia, amblyopia, near and distance deviation angles, BV, surgical dose, and duration of follow-up were investigated. SPSS  version 21.0 statistical software was used for statistical analyses using a 95% confidence interval. Fisher’s exact, Mann-Whitney U, Pearson chi-square, Spearman and t-tests were used. Level of significance was accepted as p<0.05.In group 1 (n=71), 19 (27%) female and 52 (73%) male patients underwent symmetric surgery for infantile esotropia; in group 2 (n=13), 7 (54%) female and 6 (46%) male patients underwent asymmetric surgery (p=0.098). Mean age at surgery was 7.51±5.41 years  in group 1 and 16.77±2.58 years  in group 2; the age difference between groups was significant p=0.000, .Mean refraction in spherical equivalent of each eye was 1.27±0.96 D  in group 1 and 0.69±1.40 D  in group 2 (p=0.137). BCVA varied between 0.10 and 1.00 (20/200-20/20=1.00-0.00 logMAR [logarithm of the minimum angle of resolution]). A statistically significant difference emerged in BCVA, with 0.89±0.17 (20/22.2=0.05 logMAR) in group 1 and 0.67±0.20 (20/28.5=0.15 logMAR) in group 2 (p=0.001). Anisometropia was present in 5 (7%) group 1 patients and 3 (23.1%) group 2 patients (p=0.103). Amblyopia was present in 25 (35.2%) group 1 patients and 10 (76.9%) group 2 patients, which was a significant difference (p=0.012). Preoperative BV was not detected in the 53 patients evaluated from group 1 and in the 13 patients in group 2 .Surgical success was achieved in 53 (74.6%) of the symmetric (group 1) surgeries and 11 (84.6%) of the asymmetric (group 2) surgeries (p=0.724). Duration of the follow-up period for groups 1 and 2 was 22±26.15 months  and 17.92±37.67 months , respectively (p=0.069). Postoperative BV was present in 3/60 (5%) group 1 patients and 1/12 (8.3%) group 2 patients p=0.526, .The surgically successful group 3 (n=64) comprised 18 (28%) female and 46 (72%) male patients; the surgically unsuccessful group 4 (n=20) comprised 8 (40%) females and 12 (60%) males (p=0.407). Mean age at surgery was 9.06±6.42 years  for group 3 and 8.55±4.94 years  for group 4 p=0.966, .The mean refraction of both eyes in spherical equivalent was 1.08±2.00 D  in group 3 patients and 1.52±0.87 D  in group 4 patients (p=0.113). BCVA varied between 0.10 and 1.00 in decimal and was 0.85±0.20 (20/23.6=0.08 logMAR) in group 3 and 0.87±0.18 (20/23=0.07 logMAR) in group 4 (p=0.645). Anisometropia was present in 7 (10.9%) group 3 patients and 1 (5%) group 4 patient (p=0.673); amblyopia was present in 26 (40.6%) group 3 patients and 9 (45%) group 4 patients (p=0.798). Preoperative BV was not observed in any of the 49 patients in group 3 and in the 17 patients in group 4 who were evaluated .Fifty-three (82.8%) group 3 patients and 18 (90%) group 4 patients underwent symmetric surgery; 11 (17.2%) group 3 patients and 2 (10%) group 4 patients underwent asymmetric surgery (p=0.724). Follow-up period was significantly longer in group 4  than group 3 . Postoperative BV was detected in 4 (7.5%) of the 53 group 3 patients evaluated and was not detected in any of the 19 group 4 patients evaluated p=0.567, .In patients with successful symmetric surgery  total medial rectus recession was 10.10±0.96 mm ; in patients with successful asymmetric surgery  total amount of recession and resection was 11.50±0.97 mm  (p=0.000). At the final follow-up, group 3a and 3b patients had near deviation angle differences of 41.21±8.52 PD  and 48.54±7.55 PD , respectively (p=0.010), and distance deviation angle differences of 40.9±8.35 PD  and 44.45±7.25 PD , respectively (p=0.187). The asymmetric surgery group showed significantly higher total surgical amount and near deviation angle change than the symmetric surgery group (p<0.05).Each mm of surgical procedure resulted in a mean near deviation correction of 4.05±0.64 PD  in symmetric surgeries and 4.25±0.78 PD  in asymmetric surgeries (p=0.391), and a mean distance deviation correction 4.02±0.61 PD  in symmetric surgeries and 3.87±0.60 PD  in asymmetric surgeries p=0.376, .Analysis of factors affecting response revealed a statistically significant negative correlation between age at surgery and amount of deviation correction per mm, with surgery being more effective in younger patients and deviation correction decreasing for near  and distance  as age increased. No significant correlation between age at surgery and near  or distance deviation was found.A statistically significant positive correlation was found between preoperative degree of deviation and surgical response in symmetric  surgeries and in asymmetric surgeries for near  and distance , with responses increasing as deviation angle increased.7 Contrary to these results, Tolun et al.’s8 patient group contained more girls (64.8%) and our study group included more boys (69%).Infantile esotropia is an inward deviation arising in the first six months of life, which is a critical period for the development of binocular functions. In healthy children its incidence is 0.1-1% and usually occurs equally in both sexes.7 The generally accepted opinion is that surgery should be performed as early as possible in order to achieve better BV function, within the first 24 months of life and even earlier than 6 months.13 However, Öner et al.14 reported that surgical age did not significantly affect BV development. It has been proposed that in cases in which surgery is performed early, the patient cannot be evaluated properly, other pathologies associated with deviation can be overlooked, and there may be increases in surgery number and amblyopia.12When to perform surgery on infantile esotropia patients is a topic of debate. Many studies have indicated that surgical age is important for success.2 In a study by Polling et al.15 with infantile esotropia patients matched for age, gender, refraction and deviation angle, no difference emerged between the two surgical groups in postoperative deviation angle and BV, though Bradburg et al.16 reported better results with symmetric surgery, and Önal et al.17 achieved better results with asymmetric surgery.There is also lack of consensus regarding which surgical technique is preferrable for infantile esotropia. Considering that resection is irreversible, symmetric surgery is more recommended for small children, while asymmetric surgery is recommended for older patients without alternation.18 In our clinic, symmetric surgery is usually applied in cases of alternating deviation, whereas asymmetric surgery is chosen for cases with low vision, no alternation, greater deviation angle and older age. The success rate in the symmetric surgery group was 74.6%; in the asymmetric surgery group, which had greater near deviation angles, the success rate was 84.6%. In the last postoperative follow-up there was no significant difference in deviation angles, which indicates the effectiveness of both surgical techniques in the cases for whom they were chosen based on the patients’ clinical characteristics. However, the pronounced difference in numbers of patients who underwent symmetric surgery  and asymmetric surgery  is a weakness of the study; it is believed that comparison of similarly sized groups is necessary.Age at surgery ranged in our patients between 1 and 18 years due to a delay in seeking medical help. The mean ages of group 1 and 2 patients were 7.51 and 16.77 years, respectively. Significant differences emerged in age as well as visual acuity and amblyopia. Age difference between the surgically successful (group 3) and unsuccessful (group 4) patients was insignificant . These results are consistent with studies recommending asymmetric surgery in older patients with amblyopia.19Analysis of patients’ sensory status revealed no significant improvements in BV in any of the study groups. These results are attributable to the advanced age of the patients and supports previous studies suggesting that surgery should be performed early in order to achieve BV improvement.9 As in all strabismus cases, preoperatively correcting refraction errors, treating amblyopia and establishing alternation are also important in infantile esotropia patients.8 Conversely, Kampanartsanyakorn et al.20 reported that visual acuity did not affect surgical success. Yusufoğlu et al.7 found amblyopia in 39.4% of their infantile esotropia patients and found a higher rate of amblyopia among unsuccessful surgeries. In this study, we detected amblyopia in 41.7% of all patients. We attribute the significantly higher rate of amblyopia in the asymmetric surgery group compared to the symmetric surgery group to the fact that asymmetric surgery was usually chosen for eyes with low vision.It is accepted that amblyopia has a negative effect on surgical outcome.21 For this reason, dose-response curves and surgery amount tables are only indicative, especially for surgeons who are relatively new to strabismus surgery.23In strabismus surgeries, the outcome may vary depending on the patient’s sensory status, anatomical features and surgical methods chosen, as well as the surgeon’s experience, technique and application; therefore, a procedure will not yield the same results with every patient. Outcomes are affected by many factors such as differences in how muscles are exposed, how sutures are passed, tying style and measurement of surgical amount.25 It has been claimed that recession of the medial rectus is more effective, resection has an auxillary role, and when the two are performed together, it increases the effectiveness of recession by 25%.25 Hopker and Weakley26 found a mean correction of 3 PD/mm of medial rectus recession, with no significant correlation between the dose-response curve and age at surgery or deviation angle. On the other hand, Kushner et al.24 stated that preoperative deviation angle was important in infantile esotropia patients’ response to surgical dosage.In infantile esotropia, reported correction of deviation angle per mm of medial rectus recession or lateral rectus resection ranges between 2 and 5.8 PD.26 the deviation correction per mm of recession/resection was calculated by dividing the change in deviation angle by the total amount of surgical procedure. Symmetric surgery was more successful at younger ages, with the amount of correction at near and distance per mm decreasing as age increased. With asymmetric surgery, no significant correlation was observed between age at surgery and surgical dose-response. Consistent with the results of Kushner et al.,24 in both groups the amount of correction per mm was correlated to preoperative deviation angle; larger deviation angles corresponded to larger correction per mm at near and distance.One of the aims of this study was to evaluate the dose-response effect in successful infantile esotropia surgeries performed in our clinic. As in other studies,27 Conjunctival recession has been reported by Kushner and Morton28 in infantile esotropia patients with deviations of 65 PD or larger and by Tran et al.22 and Keenan and Willshaw9 in patients with 50 PD or larger deviation angles.In this study, the amount of deviation correction per mm of muscle resecssion/resection varied between 2 and 5.71 PD depending on the deviation angle. We believe that placing only one lamellar and one full thickness suture in the medial rectus margins during recession enhances its effectiveness; during resection, ensuring that the lateral rectus is free during measurement with the strabismus caliper and placing central sutures in addition to those at the muscle margins increases the effectiveness of resection. Although they have not been compared, we are of the opinion that other factors such as cutting the check ligaments and intermuscular membranes and conjunctival and Tenon’s recession may also affect outcomes. Various studies aiming to improve surgical efficacy have recommended the addition of conjunctival recession to medial rectus recession.We have concluded that in infantile esotropia surgery, surgical technique should be chosen based on each patient’s clinical features, and each surgeon should consider the dose-response in the outcomes of procedures they have performed, as tables indicating surgical dosage can only provide initial guidance.


Clostridium difficile is the leading cause of nosocomial diarrhea and pseudomembranous colitis. The prevalence of C. difficile infection differs in various geographical areas. The aim of this study was to determine the prevalence of C. difficile isolates and the prevalence of cdd3, tcdA and tcdB genes in beef samples in Kermanshah Province.C. difficile and cdd3, tcdA and tcdB genes was assessed by PCR using specific primers.One hundred ground beef samples were randomly collected from the butchers of Kermanshah province during March 2014 to March 2015. Following alcohol shock, minced meat samples were incubated in a specific culture medium for 5 to 7 days. The suspicious colonies were analyzed by biochemical tests and frequency of C. difficile and all the isolates harbored Cdd3 gene. Combined dual-gene frequency of A+B+, A−B+ and A+B− strains in the positive were 0%, 3.3%, and 26.6% respectively, while 21 samples (70%) were non-toxigenic (A−B−).In total, 30% samples were positive for C. difficile in beef as a source of contamination was confirmed. It was also shown that the incidence of C. difficile in ground meat was relatively higher than many other studies.In this study, the presence of  Clostridium difficile is a gram positive, spore-forming obligatory anaerobic bacterium . Toxin A (tcdA) and toxin B (tcdB) genes are located close to each other on a Pathogencity Locus. Toxin A consists of 2710 amino acids (308 kDa) and toxin B consists of 2366 amino acids (270 kDa). These toxins are classified as lethal toxins among the group of large cytotoxic toxins (LCTS)  , 12.C. difficile infection in the Middle East, while the studies from rest of the world, such as Europe and North America show that infections caused by this bacterium are rapidly increasing  (Hi Media -India) enriched with 5% sheep blood and 250 μg /ml cycloserine and 8 μg / ml Cefoxitin antibiotics. Cultured Plates were incubated at 37°C under anaerobic atmosphere for 5–7 days.Suspected colonies with yellowish gray or white, round and slightly raised was identified with Gram staining.tcdA, tcdB and cdd3 was investigated by PCR using specific primers (primers were designed based on sequences retrieved from Gen Bank). Isolates that were positive for cdd3 gene in PCR were tested for tcdA and tcdB. List of used primers are shown in DNA of confirmed colonies was extracted by a kit (Sinaclon) and presence of Taq DNA polymerase and 1 μl of DNA template. The program consisted of initial denaturation at 94°C for 5 minutes and 35 thermal cycles including denaturation at 94 for 30 seconds, annealing at 54°C for cdd3, tcdA and 53°C for tcdB genes, and a final extension at 72°C for 5 minutes. PCR products were isolated by 1% agarose gel electrophoresis and resulting bands were visualized by staining with Ethidium Bromide solution.A PCR reaction was performed in a total volume of 15 μl containing1X PCR buffer , 0.2mM deoxynucleotide mix, 1.5 mM MgCl2, 0.6μM of primers, 1 unit of Data were analyzed using the SPSS 16 software. The qualitative data were analyzed using chi-square test, and in all cases p < 0.05 was considered as significant.C. difficile was positive in 30 samples (30%).Suspected colonies were identified by Gram stain and the isolates were confirmed by molecular methods. From a total of 100 samples of ground beef, cdd3, tcdA and tcdB genes were 497 bp . Among the 30 isolates, the combined dual frequency of, A+B+, A−B+ and A+B− genes in cdd3 positive C. difficile strains were 0%, 3.3%, 26.6%, respectively. Interestingly, 21 isolates (70%) were non-toxigenic (A−B)   and 2.C. difficile is an important cause of nosocomial diarrhea. Spores of C. difficile are quite widespread in the environment and foods  non-toxigenic isolates were also isolated from minced meat samples which show that the rate of non-toxigenic strains is relatively high. It was believed that all toxigenic isolates of C. difficile produce both toxins (A+B+ strains) and the toxin B is capable of inducing CDAD without the presence of toxin A (−B+).Among samples of ground beef in several areas of Kermanshah Province, the frequency of A toxin A . But, laC. difficile was 42% and also C. difficile were 42.2% 41.3% and 44.4% in beef, pork and turkey meat samples  , the prevalence of %, 56.9% . The preand 6.3% , 25. A−B (26.6%) . AccordiC. difficile of ground beef in Kermanshah province. According to studies in this field, ground meat can be a carrier for of C. difficile and transmit the bacteria to humans. Thus, control and supervision by the health organization and hygiene and sanitation and proper cooking can reduce food contamination with C. difficile. It seems that identifying virulence factors and the prevalence of these bacteria can be effective in the prevention and control of the disease (Based on the results of current study, there is a high rate of  disease , 29.C. difficile on food products would be helpful in future.Furthermore, more studies must be done in different parts of the country to determine the prevalence of the


This study analyzes the relationship between preoperative psychological states of primary palmar hyperhidrosis patients and postoperative compensatory sweating.We evaluated the psychological states of patients with primary palmar hyperhidrosis who received sympathectomy in our hospital from 2016 to 2017. The relationship between preoperative psychological states and postoperative compensatory sweating were assessed using Spearman’s rank-order correlation.P>0.05). However, the psychoticism scale displayed a strong impact on the degree of compensatory sweating (P<0.05). The higher the degree of psychoticism scale, the more serious the degree of compensatory sweating.Fifty-five patients who received R4 + R3 bypass transection accepted the preoperative questionnaire survey; 35 were males and 20 were females. The average age was 24.0 ± 6.3 years . Depression symptoms were present in 21.9% (12/55) of the patients; the incidence of anxiety was almost similar, at 23.7% (13/55). Compensatory sweating occurred in 67.3% (37/55) of the patients; of these, 56.4% (31/55) was mild and 10.9% (6/55) was moderate. None of the patients had severe compensatory sweating. There was no significant relationship between the scores of SDS, SAS, and the incidence of postoperative compensatory sweating (The results of this study showed that patients with primary palmar hyperhidrosis are more likely to have mild or moderate mental disorders, and that postoperative compensatory sweating may impact the satisfaction of surgery. In addition, the personality characteristics of patients are related to compensatory sweating. Primary palmar hyperhidrosis (PPH) refers to a chronic disease in which hands sweat more than normal due to emotional stress. The symptoms of this kind of sweating mainly appear in childhood and adolescence , charactOne of the most popular treatment of PPH in recent years is endoscopic thoracic sympathectomy , 7. It iIn this study, we evaluated the degree of depression, anxiety, and personality characteristics of patients with severe PPH, and assessed whether these psychological factors have an impact on morbidity and postoperative satisfaction.This was a cross-sectional study, which included pediatric and adult patients with severe PPH who received treatment in our hospital from 2016 to 2017. Patients who were unable to complete the questionnaire independently were excluded.All patients were assessed by the same preoperative psychologist in the same office. Each patient had to complete three copies of questionnaires independently: the Self-Rating Depression Scale (SDS), invented by Zung in 1965 ; Self-RaThoracoscopic sympathectomy was performed on all patients by the same surgical team with the patient in the Semi-Fowler’s position with both arms elevated and supported to 90° under general anesthesia using a single lumen endotracheal tube. The costal pleura on the surface of the sympathetic chain were transected at the level of the fourth rib bed (R4 sympathectomy) with diathermy. In order to amputate the potential bypass nerve fibers, we extended the transection range by approximately 2 cm laterally along the surface of the corresponding rib. Then, the bypass of R3 was also transected with diathermy; however, the sympathetic chain of R3 was preserved. A temporary 10-Fr chest tube was inserted into the pleural cavity through the surgical incision and connected to a water seal system. After re-inflating the lungs, the chest tube was quickly removed and the incision was closed. We routinely conducted the operation on the right side first, in view of the imbalanced innervation of the heart by bilateral sympathetic nerves. The same procedure was performed on the contralateral site. A postoperative routine chest X-ray was obtained for all patients the following day. Most of the patients were discharged on the same day. Patients underwent follow-up 6 months after operation. The follow-up questionnaire included assessment of improvement after treatment, CS, and quality of life.The clinical presentation of CS can be classified as mild, moderate, or severe . Mild CSp value of < 0.05 was considered to be statistically significant at the 0.05 level. Statistical analyses were performed using the SPSS statistical software version 19.0 .All descriptive statistics are expressed as the mean ± standard deviation (SD) for continuous variables. Correlations between variables were analyzed using Spearman’s rank-order correlation. A A total of 55 patients accepted the preoperative questionnaire survey; 35 were males and 20 were females. The average age was 24.0 ± 6.3 years . The patients’ age distribution were as follows: 56.4% (31/55) between the ages of 20 and 29 years, 9.1% (5/55) between 30 and 39 years, 29.1% (16/55) between 10 to 19 years, and 5.4% (3/55) over the age of 40 years (Table Depression symptoms were present in 21.9% (12/55) of PPH patients; the incidence of anxiety was almost similar, at 23.7% (13/55). Almost 40% (22/55) of the patients had at least one mental disorder; 5.4% (3/55) had two. Fortunately, none exhibited severe depression or anxiety; however, the incidence of moderate and mild depression was 5.5% (3/55) and 16.4% (9/55), respectively. The prevalence of moderate and mild anxiety was 5.5% (3/55) and 18.2% (10/55), respectively (Table P<0.05).No patients had postoperative pneumothorax, hemothorax, Horner’s syndrome, and recurrence of palmar hyperhidrosis. CS occurred in 67.3% (37/55) of the patients; of these, 56.4% (31/55) was mild and 10.9% (6/55) was moderate. None of the patients had severe CS. The regions involved in CS were the back in 54.5% (30/55), protothorax 36.4%(20/55), thigh 12.7% (7/55), shank 5.5% (3/55), hip 7.3% (4/55), head 3.6% (2/55), and axillary 1.8% (1/55). Of the 55 patients, 43.6% (24/55) had CS in more than two regions. The degree of CS was significantly dependent on the satisfaction of the patients (P>0.05) (Tables P>0.05)  Tables , the P s) Tables .Table 3RIn this study, we found that the incidence of PPH had nothing to do with gender. Patients under 20-29 years old preferred to go to a doctor; this finding was consistent with the results of the studies by Fenilli, Kauffman, and Wolosker –16.Endoscopic thoracic sympathectomy is currently one of the most common treatment for PPH. In this study, the cure rate of PPH was 100%. No patient complained of relapse.While CS is a common postoperative complication among patients with PPH, its etiology is still unclear. The location in which CS occurs is also not fixed; in this study, the site of CS occurrence was widely varied, including the back (54.5%), protothorax (36.4%), thigh (12.7%), shank (5.5%), hip (7.3%), head (3.6%), and axilla (1.8%). Of the 55 patients, 43.6% had CS in more than 2 regions.Approximately 21.9% of the patients in this study had combined mild or moderate depression, compared to the worldwide incidence of depression, which is approximately 16% . AccordiThe EPQ score for PPH patients, especially the P dimension, had a certain relation with postoperative CS. While the E, and N scale scores had no obvious relation with the postoperative CS, the P scale score showed an obvious relation; the higher the P scale score, the more severe the postoperative CS. The P scale refers to psychoticism, defined as cold, impersonal, lacking in sympathy, emotionality, empathy, and insight combined with a tendency of paranoid ideas against oneself.To some extent, there are many subjective factors in the evaluation of sweating. At present, we have not identified the etiology of CS; therefore, we could not exclude the fact that patients may have exaggerated their CS during evaluation. Compared with the SDS and SAS scales, the EPQ scale evaluates the personality characteristics of patients; these indicators can reflect the personality of patients in a more stable way. The state of depression and anxiety may be caused by the symptoms of the disease. Operations are usually associated with a quick and obvious effect, while the state of depression and anxiety may improve compared with the preoperative state. However, we should be aware that neither SDS nor SAS can represent the patients’ persistent mental state. However, personality traits are gradually formed as a person ages, and thus cannot be altered by an operation. Therefore, the EPQ scale is able to reflect personality traits’ effect on sweating more accurately. Personality traits are gradually formed as a person ages, and thus cannot be altered by an operation. Therefore, the EPQ scale is able to reflect personality traits’ effect on sweating more accurately. So we suggest that all patients with PPH should take psychological states evaluation preoperatively. And predominant high level P scale may be considered as a relative contraindication for endoscopic thoracic sympathectomy. For these patients, we should recommend medication therapy, such as oxybutynin as first line of treatment .The results of this study showed that patients with PPH are more likely to have mild or moderate mental disorder, and that postoperative CS may impact the satisfaction of surgery. In addition, the personality characteristics of patients are related to CS. All patients with PPH should take psychological states evaluation preoperatively. And certain psychic characteristics may be considered as a relative contraindication for surgery.