Introduction: Percutaneous transvenous mitral commissurotomy (PTMC) is a safe and effective procedure for relief of severe mitral stenosis. PTMC is being done widely and many transseptal procedures requiring large diameter catheters, sheaths are becoming popular. The knowledge of iatrogenic atrial septal defect (iASD) is vital. This study assessed the use of real-time 3D echocardiography (RT3DE) and incidence of iASD in a cohort of patients undergoing transseptal catheterization during PTMC.Methods: One hundred ten patients underwent PTMC. The reliability and accuracy of RT3DE for iASD detection was determined, RT3DE was compared with 2D echocardiography (2DE) for iASD occurrence, influencing variables analyzed and followed up for 1 year.Results: RT3DE is more reliable and accurate for the study of iASD than 2DE. Color RT3DE detected iASD in 94 (85.5%), with 2DE iASD was detected in 74 (67.3%) (P  < .0001).On follow up 85% had iASD post procedure, 56% at 6 months, 19% at 1 year follow up. The mean iASD diameter was 5.41 ± 3.12 mm and area 6.57 ± 3.81 mm2. iASD correlated with patient height, Wilkins score, pre-PTMC LA ‘v’, and post-PTMC LVEDP.Conclusion: RT3DE imaging is superior in accuracy to traditional 2DE techniques. All the modes of RT3DE are useful in the assessment of iASD. iASD measured by RT3DE correlates with several patient, procedural and echocardiographic variables. They have a potential for paradoxical embolism and cerebral ischemia, they are also known to affect the accuracy of post procedure mitral valve area measurements. Their natural history is of spontaneous closure in a majority; role for any form of closure is controversial and should bear the chance of repeat transseptal procedure in the future. There also is a debate to remove iASD as a complication of PTMC from literature as it occurs potentially in all cases, many studies have shown that it is of little consequence and is very difficult to characterize. Several studies over the past decades have shown the incidence of iASD to be high, but the standard diagnostic modalities to define them including oximetry, indicator dilution, two dimensional echocardiography (2DE), color flow Doppler have been suboptimal.11Atrial septal defect (ASD) is a predestined complication of the percutaneous transvenous mitral commissurotomy (PTMC), since it requires a transseptal technique.12Real time 3 Dimensional echocardiography (RT3DE) already has a proven role in pre PTMC mitral valve (MV) apparatus morphology evaluation including Wilkins score assessment and is also useful in the evaluation of potential complications including mitral regurgitation and atrial septal defects. There is a potential for RT3DE guidance for difficult or high risk procedures. Currently it can be argued that RT3DE is definitely superior to 2D imaging techniques and should be routinely used in mitral stenosis, particularly in the post PTMC period, where other methods have been proven to be inaccurate.The primary aim of this study was to investigate the feasibility of imaging by various methods of transthoracic RT3DE for evaluating and quantification of iASDs in the context of PTMC in a group of consecutively imaged patients to determine the acoustic window or perspective from which the atrial septum, location of iASD, defect area are best visualized. The secondary aim was to compare 2DE and RT3DE for the evaluation of iASDs after PTMC and to study the effect of various demographic, echocardiographic and catheterization data on occurrence of iASD.The study population consisted of 110 patients with chronic rheumatic heart disease with symptomatic mitral stenosis (MS) who underwent PTMC in cardiology department of Sri Venkateswara Institute of Medical sciences, Tirupati, between Jun 2011 and Mar 2013. After informed consent, patients with chronic rheumatic heart disease and severe MS, in whom PTMC was feasible, were included in the study. Patients with mitral restenosis after earlier PTMC or surgical mitral commissurotomy were also included. Those with non-feasible 2D or 3D echocardiography because of poor image quality or poor echo window, patients with left atrial thrombus, mitral regurgitation greater than 2/4, calcific MV and commissures, severe aortic valve disease associated with MS, critically ill patients and pregnant were excluded.13 Transesophageal echocardiography (TEE) was performed with S10 probe, iE33 echocardiography unit, Philips medical systems, USA. The patients underwent PTMC by single balloon as per guidelines and institutional norms. All patients were analyzed at baseline, post procedure, 6 months, and 12 months for the presence of an ASD. With 2DE, iASDs were identified with color flow Doppler in the apical four-chamber or the subcostal view. If an iASD was detected, the larger color flow width at the level of the interatrial septum was recorded as the iASD diameter.Comprehensive transthoracic 2DE was performed the day before and 24-48 hours after PTMC using S5 probe iE33 echocardiography unit, Philips medical systems, USA as per standard guidelines.14 The recorded datasets were analyzed on a workstation using dedicated software.15RT3DE was performed with 2DE guidance, ECG gating or auto acquisition in atrial fibrillation patients. Datasets were acquired of live 3D, 3D zoom, full volume and 3Dcolour formats. The stored datasets were post processed in the same workstation with QLAB software for qualitative enhancement and quantification  and 2. Rt test and Pearson correlation. Agreement between the two methods of assessment was analyzed by the Passing and Bablok regression analysis. Intraclass correlation coefficient was assessed for the reliability analysis. Binary logistic regression was used for the analysis of influence of the study variables. Statistical significance was defined with P<.05. Microsoft Excel (2007), MedCalc version 15.2.2 and SPSS version 20.0  was used for the organization and tabulation of results, and for statistical analysis.Quantitative variables were expressed as mean ± standard deviations and analyzed using unpaired The mean age of the patients was 35.21 ± 10.26 years (13-61 years). Majority of the patients were in the age group of 20-40 years. Out of 110 patients, 36 (32.72%) were males and 74 (67.27%) were females. Mean height was 156.54 ± 9.47 cm (130 to 180 cm). Mean weight was 49.90 ± 10.78 kg (21 to 75 kg). Nine (8.10%) out of 110 study patients had previously undergone PTMC. Two (1.8%) of the 110 study population had undergone a previous surgical mitral commissurotomy. Eleven (10%) of the study population were in atrial fibrillation.2 (0.5-1.2 cm2 ), mean post-procedure MVA was 1.75 ± 0.17 cm2 (range 1.22-2.00 cm2 ) and mean MVA change was 0.9 ± 0.19 cm2 ). The atrial septum was graded visually on TEE. Normal septum was seen in 12 (10.9%), thick septum in 11 (10%), while a majority had thin septum 82 (74.5%). Atrial septal aneurysm was noted in 5 (4.5%). Left atrial spontaneous echo contrast (LASEC) was assessed visually on TEE. Dense SEC was encountered in 51 (46.4%), mild SEC in 43 (39.1%), while no SEC was seen in 16 (14.5%) (The mean LV ejection fraction (EF) was 60.15 ± 5.75. Seven (6.4%) patients had mild LV dysfunction. Mean left atrial (LA) size was 45.55 ± 6.31 mm (33 to 65 mm). Mean right ventricular systolic pressure (RVSP) was 53.03 ± 24.53 mm Hg (16-130). The mean Wilkins score was 7.09 ± 1.21 (5 to 10). Mitral valve area (MVA) was assessed by planimetry, mean pre-procedure MVA was 0.82 ± 0.14 cm (14.5%) .P < .0001). There was significant fall in LA “a” wave peak from 23.74±13.34 to 13.33 ± 6.59 mm Hg (P < .0001) and “v” wave peak from 27.32 ± 9.08 to 14.75 ± 6.36 mm Hg (P < .0001). There was significant increase in left ventricular end diastolic pressure (LVEDP) from 5.60 ± 2.47 to 8.69 ± 3.25 mm Hg (P < .0001).Regarding the PTMC procedure, the size of the balloon was selected according to the height. The larger balloon of size 25-28 was used in 90 (81.80%) cases, 24-28 in one patient (0.90%), 22-24 in one (0.90%) and the 21-24 size balloon was selected in 18 (16.40%) cases. The number of balloon inflations per procedure ranged from 1 to 3. The mean number of balloon inflations was 1.06 ± 0.28. The inflation pressure ranged from 22 to 26 mm, with mean inflation diameter of 24.24 ± 0.69. Invasive measurements with fluid filled catheters were obtained bean before and after the procedure. There was significant fall in mean LA from 20.65 ± 7.08 to 10.24 ± 4.54 mm Hg (P < .0001). Various modes of RT3DE and 2DE were analyzed for detection of iASD in the post procedure period. The proportional positive detection of iASD and statistical significance of usefulness of all modes of RT3DE are shown in Pre-PTMC, none of the patients showed preexisting ASD on imaging by 2DE or RT3DE. Postprocedure, with color RT3DE an iASD was detected in 94 (85.5%) of patients while with standard transthoracic echocardiography (TTE), iASD was detected in 74 (67.3%) (P < .0001) , but could not be done directly by 2DE.The mean diameter of iASD measured by RT3DE was 5.41 ± 3.12 mm (range 2.5-11 mm), while 2DE measurements were smaller- mean diameter of 3.85 ± 2.83 mm (range 2-9 mm). On Pearson correlation, RT3DE is superior to 2DE for assessing the diameter of iASDs  . It was To measure the systematic, proportional and random differences between the two diagnostic methods of RT3DE and 2DE, Passing and Bablok regression method was used. Passing-Bablok compares two analytical methods, a test method against a reference/comparative method, to determine analytical accuracy. It showed that for measurement of iASD diameter, RT3DE did not have constant/proportional bias or any significant deviation from linearity . There wThe occurrence of iASD significantly and positively correlated with height of the patient, post-PTMC LVEDP, preprocedural and postprocedural LA ‘V’, pre- and post-PTMC LA mean (M), LA size, post-PTMC MVA, actual change in MVA and Wilkins score measurement .P = .04). Among the echocardiographic variables EF, LA size, pre- and post-MVA, Wilkins score and RVSP; only Wilkins score (P = .08) was significantly related to iASD. Invasive catheterization parameters of preprocedure and postprocedure LVEDP, LA ‘a’ wave, ‘v’ wave, mean pressure, PTMC balloon size, inflation diameter, number of inflations were analyzed. Pre-LVEDP (P = .02), post-LVEDP (P = .01), pre-V (P = .007) correlated significantly with the occurrence of iASD.Binary logistic regression of the demographic variables age, sex, height and weight revealed that only the patient height was influencing iASD  and 1 year (40.9%) follow-up. 2DE was uniformly less useful for iASD detection at follow-up periods .P < .0001) and area  were significantly higher than the naive patient population. On analysis of previous PTMC and iASD, there was a strong positive association (P = .03), but the association was of significance only at the 6 month follow up (P = .001) .In 11 (10%) patients who had undergone previous PTMC, the mean iASD diameter  .In 11 (10%) patients with atrial fibrillation (AF), the mean diameter and area of iASD were higher than those in sinus rhythm. Of 11 (10%) patients with AF, all had iASD postprocedure. At 6 months follow up, all 11 (10%) had a persistent iASD. At 1 year follow up, only 9 (8.2%) had iASD visualized.This is the first study to investigate iASDs after PTMC using RT3DE. The burden of chronic rheumatic heart disease is high in developing countries, with MS being the most common long-term expression of the disease. PTMC is a safe and effective procedure for relief of severe MS. PTMC requires transseptal access to the LA, which is created by puncture and dilatation of the interatrial septum by catheters. In view of widespread popularity of PTMC and many other forms of transseptal procedures requiring large-diameter transseptal catheters or sheaths, knowledge of the natural history of this inevitable complication is vital. This study assessed the use of RT3DE and incidence of iASD in a large cohort of patients undergoing transseptal catheterization during PTMC. RT3DE, once considered a research tool, is now an everyday clinical application.11 The traditional methods of iASD quantification have even more limitations. RT3DE eliminates the need for systematic imaging to detect iASD by using multiple techniques, some of which are semi-invasive or cumbersome.The atrial septum is one of the most difficult-to-visualize structures of the heart. An iASD after PTMC is variable in location and small. All the available diagnostic modalities come up short in evaluation of iASD, with reported incidences from 10% to 90%, depending on the technique used .3-11 TheP < .001). The mean diameter of iASD by 2DE was 3.85 ± 2.83 mm, significantly less than the 5.41 ± 3.12 mm by RT3DE (r = 0.92). By comparing the two analytical methods (2DE and RT3DE) by Passing and Bablok regression, any systematic (constant), proportional, and random bias was eliminated to yield the superiority of RT3DE quantitation. A more confident estimation and quantitation of iASD is possible by RT3DE because the entirety of the defect can be appreciated and planimetered by adjusting the imaging planes.In our study, 2DE (TTE) detected iASD in 74 patients (67.27%) post-procedure, less than the detection rate of RT3DE, 94 patients (85.45%). 2DE was inferior to all the individual modes of RT3DE; this difference was statistically significant (iASD size (diameter and area) was measured by one or two observers. Inter-method agreement was evaluated by means of the intraclass correlation coefficient. The analysis demonstrated a superior agreement when comparing RT3DE and 2DE; the intraclass correlation coefficient was 0.95 (CI: 0.93 to 0.97) and all individual measurements were positively correlated.Our study suggests that RT3DE is more accurate than 2DE, particularly because it was more reproducible, correlated with 2DE, and was better for quantification. The lack of a gold standard for iASD measurements (even invasive methods are not sensitive enough for iASD detection) prevents accuracy assessment but the high rates of detection, reproducibility of results, feasibility of direct (en face) quantitation, and incremental value of various methods of RT3DE suggest that it is superior to 2DE and probably other techniques used for iASD assessment.Live 3D was usually the mode used first in RT3DE. iASD was detected in 88 patients (80%). Live 3D is usually the first mode used after 2D images. Though equal to other modes of RT3DE post-procedure, it was less accurate at 1-year follow-up. Live 3D’s advantages are dynamic imaging, not requiring gating, and immediate manipulation of datasets for image enhancement and cropping without the need for post-processing; its main drawback is a narrow sector, which can be overcome by lateral steer and other techniques.3D zoom is similar to Live 3D in that a small area in the sector is selected; this provides better delineation of borders and surface rendering but can be limited by potential artifacts.Because the color 3D technique incorporates both the color and grayscale images, it helps in the initial localization of the iASD. The still frame or dynamic images give an appreciation of the shape, relative location, and size of iASD relative to the atrial chambers. With this help in initial localization, subsequent studies  were used for quantitation of iASDs. In our study, color 3D was by far the most sensitive, detecting iASD in 94 patients (85.5%) post-procedure. This trend was also appreciated during the follow-up, detecting iASDs in 61 patients (55.5%) at 6 months and in 21 patients (19.09%) at one year. Like the Live 3D, color 3D also employs a narrow sector, which was not a huge drawback for the study of atrial septum. Color bleeding and aliasing with regurgitant jets from mitral or tricuspid valve was rare; the main impediment in using 3D color clinically was that it required post-processing.Full volume datasets are the mainstay of quantification with the QLAB software, providing various tools for image enhancement, cropping along 3 dimensions  or any plane, measurement of iASD in all three axes, and planimetry. The main drawbacks are storage issues, such as large datasets, requirement of gating, and the need for dedicated post-processing.The occurrence of iASD in the postprocedural period significantly and positively correlated with height of the patient, post-PTMC LVEDP, preprocedural and postprocedural LA ‘V’, pre- and post-PTMC LA mean (M), LA size, post-PTMC MVA, actual change in MVA, and Wilkins score measurement. This probably reflects the anatomy of the atrial septum, severity and chronicity of MV disease, and LA remodeling affecting the procedure of PTMC, requiring more catheter manipulation, additional trauma to the atrial septum, and possibly suboptimal PTMC outcomes.P = .04), Wilkins score (P = .08), pre-PTMC LVEDP (P = .02), post-PTMC LVEDP (P = .01), and pre-PTMC ‘v’ (P = .007) correlated significantly with the occurrence of iASD.Logistic regression analysis of all the clinical, echo, and procedural parameters revealed that only patient height . iASD area assessed by RT3DE was also higher in AF (9.8 ± 1.2 vs 6.84 ± 3.84) and the association was significant (P < .004). The persistence of iASD in AF was high at 1 year . The apparent lack of serious adverse events like paradoxical embolism or stroke may be because all AF patients were on either antiplatelet and/ or anticoagulant medications.The influence of AF on iASD was not studied in the post PTMC population in earlier studies. The iASD diameter was larger in AF patients; this difference was statistically significant /stroke in the patients with iASD at up to 12 months of follow-up. Although only the clinical consequences of right-to-left shunting in patients with an iASD are frequently of concern, one cannot ignore the possible detrimental consequences of left-to-right cardiac shunting (right heart volume overload and pulmonary hypertension). In the absence of any clinically relevant adverse events, the need for specific therapy to be instituted or rigorous surveillance by various diagnostic techniques is not clear.The presence and magnitude of any shunt will probably also be related to catheter size and the amount of trauma at the site of the atrial septal dilation. The procedural factors, such as balloon size, number of inflations, and inflation pressures, were not related to the occurrence of iASD. The factors associated with iASD were patient height, Wilkins score of MV, pre-PTMC LA ‘v’, and post-PTMC LVEDP, probably reflecting the influence of anatomical variations, more severely diseased valves, and higher LA pressures; these predict greater technical difficulty, resulting in additional trauma to the septum. Additionally, an optimal PTMC procedure that restores good hemodynamics may influence iASD.Specific subgroups, like earlier mitral valvular interventions (previous PTMC) and AF, may be at risk of persistent iASD. Those with right-to-left shunting may benefit with judicial use of anti-platelet drugs or anticoagulants; further studies are warranted in this aspect.RT3DE has proven value and superiority in the context of PTMC, for accurate Wilkins scores, MVA assessment, and detection of complications and is preferred especially in the post PTMC period, when other methods are inaccurate. Hence RT3DE should be integrated into routine echocardiographic examination and could replace traditional 2DE methods in relation to PTMC.RT3DE imaging is superior in accuracy to traditional 2DE techniques and can be used to quantify the iASD in the period after PTMC. All the modes of RT3DE are useful in the assessment of iASD; full volume datasets were more useful for quantitation. RT3DE is reliable and provides consistent results, irrespective of the operator. iASD measured by RT3DE correlates with several patient, procedural, and echocardiographic variables. RT3DE continues to be superior for follow-up evaluation of iASDs.The incidence of iASD is high immediately after PTMC (85.5%); their detection depends on the type of imaging used, and there is a high rate of resolution of iASD, as only 19% have a residual iASD at one-year follow-up. iASDs occur most commonly in the fossa ovalis region; right-to-left shunt across an iASD is very rare. The persistence of iASD is higher in subgroups like those with a previous PTMC or AF. The strength of our study lies in it being one of the first applications of RT3DE for iASD after PTMC, with a systematic imaging protocol, large sample size, long follow-up period, statistical proof of the reliability and accuracy of results, and a clinical perspective on RT3DE and iASDs.The ability to detect iASD after transseptal catheterization will depend on the attention given to the interatrial septum and the imaging modality used. We used transthoracic RT3DE alone, and this may underestimate the actual incidence of iASD. RT3DTEE, while the best option to visualize the atrial septum, was not used for the study, as it is semi-invasive and does not provide extra information on other aspects of post PTMC assessment besides adding to the cost. We could not determine the exact location of the puncture site—a possible contributing factor in the development of iASD—because the septostomy had been performed without the guidance of TEE. iASD morphology and rims were not analyzed in this study and shunt fractions were not calculated, RT3D contrast Echo was underutilized, and only two patients showed right-to-left shunts by the study. Although this study proves the reliability of RT3DE, it still needs dedicated post-processing and has a steep learning curve. Follow-up was for one year, which, though longer than many studies, may not have been adequate to study the natural history of these iASDs. The follow-up period may not have been adequate to document the rare complications, like paradoxical embolism with brain abscess and TIA/stroke or minor associations, like migraine.This study was conducted with the approval of the Institutional ethics committee of Sri Venkateswara Institute of Medical Sciences (SVIMS). There was no economic burden on the participating patients. All investigations were performed as part of routine investigations. In accordance with the ethical guidelines of the 1975 Declaration of Helsinki, informed consent was obtained from each participant.None.


The mains topics of this work are the incidence of patient-prosthesis mismatch and the influence in the early results of isolated aortic valve surgery.In 193 patients isolated aortic valve surgery was performed. The study population was divided in three subgroups: 20 patients with severe, 131 patients with moderate and 42 patients without patient-prosthesis mismatch. The indexed effective orifice area was used to define the subgroups. Operative mortality and perioperative complications were considered the indicators of the early results of aortic valve surgery.The incidence of severe and moderate patient-prosthesis mismatch was respectively 10.3% and 67.8%. Hospital mortality and perioperative complications were: mortality 5% vs. 3.1% vs. 2.4% (p = 0.855), low cardiac output 5% vs. 6.9% vs. 4.8% (p = 0.861); pulmonary complications 5% vs. 3.1 vs. 0.0% (p = 0.430); exploration for bleeding 5% vs. 0.8% vs. 2.4% (p = 0.319); atrial fibrillation 30% vs. 19.8% vs. 11.9% (p = 0.225); wound infection 5% vs. 0.8% vs. 0.00% (p = 0.165), respectively for the group with severe, moderate and without patient-prosthesis mismatch.Patient-prosthesis mismatch is a common occurrence in aortic valve surgery. This phenomenon does not affect the early results of aortic valve surgery. Patient prosthesis mismatch (PPM) is one of the most controversial issues related to the aortic valve replacement. It is introduced in 1978 by Rahimtoola as a condition in which the effective prosthetic valve area, after insertion into the patient, is less than that of a normal human valve [a)Effective orifice area “in vivo” and “in vitro” of the prosthesis; andb)The patient’s small native valve annulus.2/m2. Patient prosthesis mismatch has been classified as moderate when 0.65 cm2/m2 ≤ EOAi ≤ 0.85cm2/m2 and severe when EOAi < 0.65 cm2/m2.In practical terms, to define PPM currently, the most used parameter is prosthetic effective orifice surface area indexed with the patient’s body surface (EOAi). Based on this index, threshold for the appearance of PPM is 0.85 cmPatient-prosthesis mismatch is a common occurrence after aortic valve replacement. The reported prevalence of moderate PPM varies between 20–70%, whereas that of severe PPM is between 2% and 11% [The mains topics of this work are the incidence of patient-prosthesis mismatch in aortic valve surgery and the influence of these findings in the early results.2). Hospital mortality and major complications such as low cardiac output, cerebral accidents, pulmonary complications, renal disorders, wound infection etc. were considered end-points for the evaluation of early results of aortic valve surgery.Our study was a prospective and retrospective study. All patients underwent isolated aortic valve surgery from January 2010 to January 2015 in two cardiac surgery centres, public and non-public, in Tirana . Patients who had additional surgical procedures were excluded from the study. Demographic data, intervention and postoperative data were collected from hospital records in the statistics office. Preoperative evaluation of risk of intervention was made according to EUROSCORE , 7. IndeA full midline sternotomy was performed. After establishing cardiopulmonary bypass and clamping the aorta, myocardial protection was provided by intermittent antegrade cardioplegia. We used to do the first dose crystalloid and after warm blood cardioplegia; transverse aortotomy; resection of the native aortic valve cusps and meticulous decalcification of the aortic annulus. All prosthesis were implanted with mattress technique, using double-armed, pleged-suported TiCron 2/0 suturesThe heart was de-aired and the aortic clamp removed after the closure of the aorta. At the end of the operation the cannulas was removed and protamine was given. Temporary pacemaker (PM) wires, mediastinal, and pleural tubes were placed before chest closure.Continuous data were presented at the mean value and standard deviation. Discrete data were presented in absolute value and percentage. Differences between the two groups for continuous quantitative variables were performed by ANOVA test one way, the Bonferoni procedure. Differences between groups for discrete variables were performed by Chi-Square test. Relations between variables were analyzed through Pearson correlation coefficient (for quantitative variables) and Kendall’s Tau (for discrete variables). Presentation of the data was performed through simple and composed tables, as well as graphics like scatter diagram, bar-diagram and Box-plott. Data analysis was performed with SPSS statistical package, version 20, . It was considered significant values of p ≤ 0.05.In the study were included 193 patients that performed isolated aortic valve surgery. Patients were divided into three groups according to the degree of PPM: 20 patients with severe PPM; 131 patients with moderate PPM; and 42 patients without PPM.General demographic and clinical data are presented in The mean population’s age was 59.53 ± 12.73. Groups with PPM had significant higher mean age comparing to other groups; 124 patients (64.6%) were males. The incidence of co morbidities was without significant statistical differences among groups except diabetes mellitus and arterial hypertension that predominate in the group with the moderate PPM. BMI was importantly greater in groups with PPM. There were no significant differences in the preliminary calculation of intervention risk.Transthoracic echocardiography and transesophagical echocardiography were the main diagnostic tools. There were 121 patients (62.7%) with pure aortic stenosis; 44 patients (22.8%) with aortic insufficiency and the rest of the patients ). Echocardiography data were presented in the The echocardiography data showed that aortic stenosis was the dominant pathology  in our population and annular calcification is encountered much more often in the PPM groups.Incidence of patient-prosthesis mismatch: incidence of severe PPM was 10.3% (20/193); and incidence of moderate PPM was 67.8% (131/193).Early mortality and postoperative complications: overall mortality was 3.1% (6/193); mortality of the group with severe PPM was 5% (1/20 pt); mortality of the group with moderate PPM was 3.1% (4/131 pt); and mortality of the group without PPM was 2.4 % (1/42 pt).We can see that in absolute value, mortality in the groups with PPM is higher but this difference is not statistically significant (p = 0.855). The incidence of postoperative complications respectively for the group with severe PPM, moderate and without PPM was: low cardiac output 5% vs. 6.9% vs. 4.8%; pulmonary complications 5% vs. 3.1 vs. 0.0%; bleeding 5% vs. 0.8% vs. 2.4%; atrial fibrillation 30% vs. 19.8% vs. 11.9%; wound infection 5% vs. 0.8% vs. 0.00%; ventricular arrhythmias 5 % vs. 4.6 % vs. 9.5 %; conduction disturbances 10% vs. 6.9 % vs. 11.9 %There is a trend towards higher frequency of complications in the groups with PPM but the differences did not reach statistical significances .Postoperative times in intensive care unit and hospital stay are longer in the group with PPM but the difference is not important. The mean prosthesis number used is 21.59 ± 1.88. It is clear the significant difference of mean prosthesis number between groups (p < 0.001). The maximal prosthesis gradient of the PPM groups are much higher in comparison with the group without PPM (p = 0.022) .The following diagrams show correlation of PPM with the patient’s age, BMI, BSA, the number of prosthesis, gender.This is the first time that the incidence of PPM in aortic valve surgery has been reported in Albania. It is 10.3% for severe PPM and 67.8% for moderate PPM. Pibarot and Dumesnil refers that the incidence of severe PPM varies 2-11 % whereas that of moderate PPM 20-70% .2 / m2. In our study we used traditional point of references: 0.65cm2 / m2 ≤EOAi≤0.85cm2 / m2 for moderate PPM and EOAi < 0.65 cm2 / m2 for severe PPM. It seems that in our study group who underwent isolated aortic valve surgery, the PPM incidence is similar to other clinics. It remains an usual phenomenon.We note that EOAi values that are taken as point references for the presence or not of PPM were different in various studies and they range from 0.7-0, 85cmThe fact that this is common occurrence opened the debate about its impact on the results of aortic valve surgery. This debate is nowadays still open.In our study, the majority of the indicators of early operative results such as mortality, low cardiac output, pulmonary complications, bleeding, atrial fibrillation and wound infection have higher incidence with the patient-prosthesis mismatch group compared with the group without this phenomenon. The overall mortality is 3.1% while in the group with severe PPM mortality was 5% in the group with moderate PPM 3.1% and for the group without PPM 2.4%.Kaminishi et al, in a study, which involved 3609 patients with isolated aortic valve surgery, refer early mortality 2.2% for the group without PPM and 3.9% for the group with PPM. These are similar to our results. Despite mortality in the group with the PPM is greater, this difference is not significant. PPM importantly affects only the duration of stay in intensive care unit and respiratory assistance . JamiensAt the same time, there are many studies, which refer PPM as an important risk factor in early results of aortic valve surgery , 16-18. Hernandez et al in a study very similar to this study, noticed that the mortality in the group with PPM was approximately 8.2%, while in the group without PPM, was 0.7%, with significant difference (p = 0.004), while for complications such as acute myocardial infarction, stroke, bleeding, post operative atrial fibrillation, pneumonia, the need for respiratory assistance, there is a tendency to have a higher incidence in the group with PPM and some of these differences are important and similar to this study. In conclusion, this group refers PPM as an important negative risk factor in early results in aortic valve surgery . PPM is An interesting study that was published by Foster and colleagues, which refer that PPM increases operative mortality not significantly, but PPM impairs importantly muscle mass regress and in conditions when hypertrophy is an important risk factor for mortality, PPM may be a risk factor . PatientThe controversy regarding the impact of early results of prosthesis- patient mismatch will probably continue. In this study, it seems that even PPM is a usual occurrence and does not influence negatively these results. Maybe in the future we will need to study this argument in special groups of patients such as in elderly patients or in patients with important left ventricle dysfunction. Furthermore, to determine the attitude towards PPM, it is very important to study this impact in long-term results of aortic valve surgery.In conclusion, patient-prosthesis mismatch is a common occurrence in aortic valve surgery. This phenomenon does not affect the early results of aortic valve surgery.


In Ethiopia, the most widely used disinfectant is 5% Hypochlorites. However, Ethiopian national health safety and infection prevention guideline recommendation on the use of bleach is not consistent and varying from 0.1%-4%. The purpose of this study was therefore to assess the effective time-concentration relationship of sodium hypochlorite against Mycobacterium tuberculosis complex isolates in the absence of any organic load.8 CFU/ml prepared using normal saline containing 0.5% tween 80. From 5% stock, 0.1%, 0.5%, 1% and 2% bleach was prepared. A 1ml of test strain suspension and 1ml of bleach mixed and allowed to stand until the specified time achieved, neutralized by 48 ml phosphate buffer. 100µl from the diluted sediment were spread on two L-J mediums and incubated at 37°C for 8 weeks.This experimental study was conducted in Bahir Dar Regional laboratory from February-June 2013. Test suspensions of 1.5 X 103 CFU/ml growth (ME = 4.4) which was inefficient. However, when the time increased, the log10 reduction was acceptable, ME >5 and it was effective. The bleach solution containing 0.5% and above was effective in all respective times. In this study, there is no difference observed in the tuberculocidal activity of bleach against resistant and sensitive strains.When 0. 1% bleach was used for 10 min, majority 11/20 of isolates showed 3 x 10Our study showed that in the absence of any organic load, 0.1% bleaches over 15 min and 0.5% bleaches over 10 min was found to be tuberculocidal. Antiseptics and disinfectants are extensively used in health care settings for a variety of purposes. A wide variety of active chemical agents (“biocides”) including phenols, aldehydes, biguanides, surface-active agents, halogens, alcohols, iodine and others have been used for hundreds of years , 2. MostDifferent studies indicated thatMycobacteria are well known for their resistance to disinfectants , 7, 8. TThis experimental quantitative suspension test study was conducted in Bahir Dar Regional Health Research Laboratory Center (BRHRLC) from February-June 2013. In quantitative methods, the number of surviving organisms is counted and compared to the original inoculum size. By subtracting the logarithm of the former from the logarithm of the latter, the decimal log reduction or microbicidal effect (ME) was obtained. A ME of 1 equals to a killing of 90% of the initial number of bacteria, ME of 2 means 99% killed. A generally accepted requirement was a ME that equals or was greater than 5: at least 99.999% of the germs were killed.0C for maximum of 8 weeks. Test strain suspensions were prepared by suspending harvested MTBC grown on Lowenstein Jensen (LJ) media in sterile normal saline containing 0.5% Tween 80 and homogenizing them for 1 min with sterile glass beads to obtain 1.5 X 108 CFU/ml. The concentration of available chlorine in bleach can be expressed in percentage, parts per million (ppm) and g/l. The currently used stock solution of bleach  contains 5% chlorine. From this 5% stock, we prepared 0.1%, 0.5%, 1% and 2% fresh working bleach using the following formula [Specimens were collected using 50ml falcon tubes from all zones of ANRS, transported to BRHRLC based on WHO recommendation; Biological substance category B, UN-3337 standards. The collected specimens processed and decontaminated by the conventional N-acetyl-L-cysteine -NaOH (NALC-NaOH) method. After decontamination, the concentrated sediment was re-suspended in 1.0 ml sterile phosphate buffer . From this, 100 µl of sediment was inoculated on two Lowenstein Jensen (LJ) mediums and incubated at 37 formula .C1V1 = C2V2Where V1 = the volume of stock solution required to prepare working solution, C1= the concentration of chlorine in the stock solution expressed in percentage, V2= the volume of newly prepared working solution from the stock and water, C2= the concentration of chlorine in the newly prepared working solution. For one patch we prepared 60ml of each of working solution  as follows.C1V1 = C2V2; 5% V1 = 0.1%60ml60ml of 0.1% 1000ppm) bleach solution had been prepared by combining 1.2 ml of 5% beach with 58.8 ml of sterile distilled water. All the other working solution prepared in the same fashion. Moreover, our percentage working solution have been used by converting in to ppm using the formula below [00ppm ble8 CFU/ml of test strain was added, mixed by vortex and allowed to stand until specified time achieved  from the diluted sediment were spread on two L-J agar medium and incubated at 37°C for 8 weeks. Controls for each suspension contained 2 ml of equal volumes of sterile normal saline and strain suspension making the final concentration of 7.5x107CFU/ ml prepared. From this control, 100µl inoculated on two L-J agar medium and incubated the same way as test strain suspension. Growth colony graded, and the grade translated in to number of colonies. CFU/ml from control-CFU/ml from disinfectant added growth gave log10 reduction or ME. Effective concentration and time considered when the capacities to cause up to a 5-log (99.999%) reduction in CFU/ml of MTBC or ≥5 ME.One ml each of  freshly prepared bleach was added in to 5 test tubes of 50 ml capacity. The remaining bleach was used for pH and temperature measurement. From 1 ml of bleach, 1 ml of 1.5 X 10achieved . PhosphaThe data were captured using data collection forms. It comprised of the Strain ID, room temperature, temperature, PH, and dilution (0.1% to 5%) of bleach, and the growth result of test organism in culture with respect to their exposure time in minutes .HANNA instruments inc.USA).Neutralizers used in this study have been verified in accordance with Ethiopian tuberculosis culture laboratory neutralization practice during sputum processing and 48 ml of PBS (PH = 6.8) was used. The sterility of reagents and media, and the performance of the LJ media have been verified. Moreover, the temperature of the room and the incubator was monitored daily using calibrated thermometer. Furthermore, the pH and temperature of bleach was measured using microprocessor based pH bench meter , OCl- (hypochlorite anion) and Cl2 (dissolved chlorine gas) in aqueous solution.Combined chlorine: chlorine in water in chemical combination with ammonia to form inorganic amines, or with organic compounds to form organic amines.Total chlorine: the sum of free and combined chlorine. For clean water, the total chlorine is essentially equal to free chlorine. When chloramines are present the total chlorine will be higher than the free chlorine.Efficacy: is the ability of bleach to completely destroyed MTBC.Biocide: a chemical agent that inactivates microorganisms.Synonym: Chlorine Bleach, Bleach, Soda Bleach, Chlorox; Sodium Hypochlorite, 5% Available Chlorine.Ethical clearance and permission obtained from the Department ethics committee of Amhara Regional State Health Bureau and letter of support and clearance obtained from research and technology transfer core process.0C which was higher compared to other lower working solutions. In this study, we found that the pH of bleach decreased as concentration of bleach decreased , 6/20 (30%) showed 5 x 103 CFU/ml growth (ME = 4.2) and the rest 3/20 (15%) showed 57 CFU/ml growth (ME = 5.9). This showed that 0.1% bleach for 10min exposure was ineffective. It was unable to produce more than a 5-log10 (≥5 ME) reduction in all tubes. However, when the time increased , the log10 reduction was acceptable, ME >5 and it was effective. The sodium hypochlorite solution containing above 5,000 ppm (0.5%) of available chlorine was effective in all respective times, producing above 5-log10 reduction  of isolates showed 3 x 10eduction . Moreove- are about equal, and as the pH goes above 7.4, increasing proportions of OCl- are present [- [We confirmed that the pH and efficacy or log reduction ability increased as the concentration of chlorine increased. This seems contrary to what literatures claimed on pH and efficacy of bleach. When the pH is between 2-7, the equilibrium favors HOCl. As the pH falls below 2, the main form is Cl2. At a pH of 7.4, HOCl and OCl present . Maximumesent [- , 7, 12. esent [- . Anotheresent [- .M. tuberculosis in 1minute [M. tuberculosis in sputum was successfully sterilized by adding equal volumes of 15% bleach for one minute, 6% for five minutes or 3% for 20 minutes [M. bovis after 2min and 5 min exposure by 0.05% bleach was 43 and 0 CFU/ml respectively indicating that increasing time at equal concentration of hypochlorite is found to be tuberculocidal. However, the results obtained in this organism cannot be considered relevant when dealing with slow-growing Mycobacteria [M. tuberculosis (H37Rv) and M. bovis. In this study, there is no difference observed in the tuberculocidal activity of bleach against resistant and sensitive MTBC strains. Bacterial resistant to antibacterial agents is either a natural property of an organism (intrinsic) or acquired. However, to date, plasmid or transposon-mediated resistance to biocides has not been demonstrated in mycobacteria [Studies conducted in different countries revealed different results on the efficacy of bleach against tuberculosis. Higher concentrations, 1%  of chlorine are required to kill  1minute . However 1minute . Its con 1minute . M. tube minutes , 17. Likbacteria . Becausebacteria . A totalbacteria .The study showed that 0.1% bleach over 15min and 0.5% bleach over 10 min was tuberculocidal in the absence of any organic load. However, decontamination of tuberculosis containing sample required higher concentration of bleach . Moreover, this study confirmed that there was no difference in the bleach, disinfectant in susceptibility of sensitive and resistance MTBC stains. Currently, Ethiopian National and Regional Mycobcteriology laboratories are using 2% bleach for 60 min for decontamination of leftover sputum samples before taking it for incineration. According to this finding, this practice is over use of bleach. It is advisable to use the correct and appropriate concentration of bleach. There is no any additional benefit using dilution that is higher than what is recommended. It will only be more expensive as you will be purchasing more chemical. Moreover, using high concentrated bleach result in health risks. Infection Control Committees in health care facilities, made up of doctors, nurses and/or decision makers are responsible deciding and approving the effective concentration-time of bleach, disinfectants and cleaning methods to be employed for each component of their medical facilities.


Introduction: Diabetes mellitus is associated with severe microvascular and macrovascular complications with major implications for public health. Diabetic neuropathy is a very problematic complication of diabetes mellitus. It is associated with severe morbidity, mortality, and a huge economic burden. The present study was designed with two aims: 1) to analyze the association of diabetic neuropathy with the glycemic index  in patients with Type 2 diabetes, and 2) to analyze the association of diabetic neuropathy with time passed since the diagnosis of diabetes.Methods: This case-control study was undertaken between June 2013 and February 2015 in the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan. Type 2 diabetics with an age range of 30-60 years were recruited from outpatient departments of AFIRM, Rawalpindi. Data were collected and recorded on a form with four sections recording the following: 1) demographics of patients and number of years passed since diagnosis of diabetes; 2) clinical examination for touch, pressure, power, pain, vibration, and ankle reflex; 3) nerve conduction studies for motor components of the common peroneal nerve and tibial nerve and the sensory component of median nerve and sural nerve; 4) glycemic index, including fasting blood glucose levels (BSF), random blood glucose (BSR) levels, and HbA1c levels. Data were analyzed in SPSS v. 20. Chi-square and phi statistics and logistic regression analysis were run to analyze associations between diabetic neuropathy and time passed since diagnosis of diabetes and glycemic index.Results: In total, 152 patients were recruited. One-half of those patients had neuropathy (76 patients) and the other half (76 patients) had normal nerve function. The mean (standard deviation [SD]) duration of diabetes was nine years (6.76), BSF levels 7.98 mmol/l (2.18), BSR 9.5 mmol/l (3.19), and HbA1c 6.5% (2.18). Logistic regression analysis predicted 87.5% of the model correctly. Duration since the diagnosis of diabetes and HbA1c levels were significantly associated with the diagnosis of neuropathy in diabetics.Conclusion: The presence of diabetic neuropathy was significantly associated with HbA1c levels and the duration of diabetes. In recent years, diabetes mellitus has become a serious public health concern in the developing world. In 2014, the nationwide prevalence of diabetes mellitus was estimated at 6.8% in Pakistan, with 87,548 diabetes-related deaths and a mean expenditure of $56 (USD) per person ) duration of diabetes was nine years (6.76), BSF levels 7.98 mmol/l (2.18), BSR 9.5 mmol/l (3.19), and HbA1c 6.5% (2.18). Detailed results of these variables with frequencies and Chi-square values are reported in Table A logistic regression was performed to ascertain the effects of BSR, BSF, HbA1c levels, and duration since diagnosis of diabetes on the likelihood that participants have diabetic neuropathy. These covariates predicted 87.5% of the model correctly. Out of four predictor variables, only two were statistically significant: HbA1c and duration since diagnosis of diabetes Table . DiabetiAccording to the logistic regression analysis, diabetic neuropathy exhibited a weak and marginally significant association with BSR levels (P = .048). Diabetics with BSR levels > 11.1 mmol/l had 3.7 times (95% CI= 1.01 - 13.34) higher odds to exhibit neuropathy. Diabetic neuropathy is a severe complication of diabetes, and it is associated with multiple risk factors. This study evaluated the association of duration of diabetes mellitus and glycemic control with diabetic peripheral neuropathy. According to our analysis, both poor glycemic control and longer duration were significantly associated with diabetic neuropathy.A long duration of diabetes and poor glycemic control is associated with increased production of glycosylation end products, metabolic derangements, endothelial injury, and oxidative products -18. OgueIn the present study, a logistic regression model consisting of duration of diabetes, HbA1c, BSF, and BSR predicted 87.5% of the occurrence of diabetic neuropathy in the study sample. Patients with an HbA1c > 6.5% were 16.9 times more likely to develop neuropathy. The role of poor glycemic control and chronic hyperglycemia as a risk factor for diabetic neuropathy has also been established in several longitudinal studies -24. The There is overwhelming evidence that timely screening with earlier detection and intervention would be useful in preventing the progression of neuropathy and reduced risk of complication in other organs -39. EffeDiabetic neuropathy is a very problematic complication of diabetes. It is significantly associated with HbA1c levels and duration of diabetes.


This study investigated early and midterm outcomes after valve-sparing aortic root replacement  for acute aortic dissection or ascending aortic aneurysm in a single Chinese hospital center.Between September 2005 to July 2013, 38 patients  underwent VSSR procedure with De Paulis valsalva graft for acute aortic dissection or ascending aortic aneurysm and were followed up clinically and echocardiographically.Among the 38 cases studied, intensive care unit stay duration was 34.5  days; hospital stay duration was 11.7 ± 7.9 days; operation time was 6.8 ± 1.9 h; and cross-clamping time was 154.4 ± 42.0 min. There was one intraoperative conversion to Bentall procedure; one re-operation for bleeding; one operative death and one case who developed complications. Mean follow-up was 39.7 ± 21.7 months . At 5 and 10 years, overall freedom from valve replacement was 94 % and 87 %; freedom from aortic regurgitation grade II or higher was 94 % and 91 %; and freedom from reoperation was 94 % and 90 % years, respectively.The reimplantation type of valve-sparing procedure appears to be facilitated by the use of the De Paulis valsalva graft with satisfactory perioperative and midterm results. Until the introduction of valve-sparing aortic root replacement (VSSR) in 1992 . We repon = 38) was 45.5 ± 12.4 years ; 84.2 % were male; mean body mass index (BMI) was 21.78 ± 8.4; 18 (47.4 %) patients were greater than NYHA class 3; EuroScore II was 13.9 ; 22 (57.9 %) patients had greater than moderate aortic valve regurgitation; 7 (18.4 %) patients had Marfan syndrome and LDS; and 16 (42.1 %) had aortic dissection. Following guidelines [From September 2005 to July 2013, 38 patients  underwent VSSR procedure at Anzhen Hospital, Beijing. As summarized in Table All procedures were performed through a median sternotomy using cardiopulmonary bypass. Patients undergoing isolated aortic root replacement received right atrial two-stage and central aortic cannulation. In most cases, antegrade cerebral perfusion was used throughout the period of hypothermic systemic circulatory arrest. After ascending aorta was clamped, the aorta was then transected, the aortic cusps were carefully inspected for prolapse, tears, calcification and perforations. After careful assessment of pertinent parameters to determine VSSR procedure methodology, the root was circumferentially dissected down to the aortic annulus nadir and each coronary artery was sutured as a button, freed and mobilized. A De Paulis valsalva graft  was secured to the aortic annulus and passed on a horizontal plane below the aortic cusps. Three aortic junction crests were anchored with 4–0 prolene suture inside the valsalva graft and throughout the graft wall up to the height mark. The aortic annulus then were sutured inside the valsalva graft using interrupted 2–0 polypropylene horizontal mattress sutures, passed though the wall of the graft and tied on the outside. The graft was re-implanted on the left ventricular outflow, and the coronary buttons then were re-implanted on the graft using 6–0 polypropylene. The distal anastomosis of the graft was continuously sutured to the aorta with 4–0 prolene  . To obtain follow-up information, clinical staff would first contact patients via phone. If patient could not be reached by telephone, letters were sent to the patient’s address. No patient was lost to follow-up in the early stage. Follow-up echocardiography was performed and evaluated for all patients. Postoperative death and repair failure requiring reoperation  after VSSR were defined as adverse events. Intraoperative conversion to a valve-replacing procedure due to severe valve regurgitation also was considered an adverse event .Data are presented as number and percentage for all discrete variables. Continuous variables are presented as mean ± standard deviation or median and interquartile range. Group comparisons were performed using the student t test for normally distributed variables, the Mann–Whitney U test for ordinal variables, and the Fisher exact test for categorical variables. A The VSSR procedure was performed in 37 patients, and one patient underwent intraoperative conversion to Bentall procedure. Within 30 days, there was one (2.6%) death secondary to lung infection coupled with multiple organ failure; 16 (42.1 %) emergency operations; and one (2.6 %) patient required re-exploration for bleeding. Additional procedures included CABG in 4 (10.5 %) patients; and arch and “trunk” procedure in 16 (42.1 %) patients. Five (13.2 %) patients developed psychiatric symptoms, and 3 (7.9 %) acute renal failure.p < 0.001, Table Mean duration of intensive care unit stay was 34.5  hours; and mean hospital stay was 11.7 ± 7.9 days. At discharge, mean operation time was 6.8 ± 1.9 h, and mean cross-clamping time was 154.4 ± 42.0 min. Aortic regurgitation less than grade I was documented echocardiographically in all 37 patients  after the VSSR procedure, a significant reduction from the baseline of 20 , there was one death (2.7 %) secondary to lung infection within one year; one patient (2.7 %) experienced worsening of aortic regurgitation requiring reoperation and underwent aortic valve replacement; and the degree of regurgitation remained constant in most patients.P = 0.211).At 1 and 5 years, overall freedom from valve replacement was 94 % and 87 %; freedom from aortic regurgitation grade II or higher was 94 % and 91 % (included the one patient re-operated for aortic insufficiency); and freedom from reoperation was 94 % and 90 % years, respectively. Freedom from reoperation in patients without additional cusp repair was 92 % and 87 % at 1 and 5 years, respectively, which was not significantly different from those patients who required additional cusp repair , with a higher EuroScore II (23.4 ± 7.2), and smaller maximum aortic root diameter (44.7 ± 7.6 mm). The VSSR procedure appears to have been a good choice for these patients, however, further follow-up data are warranted.Third, although VSSR procedure was reserved for cases with absence of severe aortic regurgitation, and presence of trileaflet aortic valve and normal cusps, it was performed in 2 cases or bicuspid aortic valve and 7 Marfan syndrome cases to honor patient’s desire for freedom from lifelong anticoagulation dependency. Although perioperative outcomes of VSSR were favorable, which could be related to the young age of the patients , long-term durability of VSSR is unknown in these cases because mean follow-up was 39.6 months . If the conclusions of this study can be extended to these patient subsets, the valve and cusp repair strategies could further change the surgical approach in bicuspid aortic valve and Marfan syndrome cases .This study has several limitations, including its small sample size, and limitations in statistical power to comparatively analyze subset of patients , 13. DesThis procedure appears to be a safe and appropriate alternative method to mechanical composite valve graft root replacement in patients who wish to avoid anticoagulation dependency with warfarin.


In “Kronhodestudien” (KS) published in 2007-2009 we followed a cohort of 80 patients with chronic daily headache one year after withdrawal therapy and found that headache improved by > 50% in a third, and a third did not improve .To examine whether adverse childhood events is associated with chronic headache and prognosis after withdrawal therapy.All 80 patients from the KS study were invited to a follow-up in 2013. Headache was registered, and a questionnaire concerning Adverse Childhood Events (ACE) was delivered to KS patients and controls without headache or other chronic pain. The study was performed anonymously and approved by the ethical committee.Sixty-six KS patients (73% women) and 69 controls (70% women) were included. Total ACE score was higher in patients [1.6 (1.1-2.1)] than in controls [0.9 (0.5-1.3)], p=0.02. Reporting sexual violation was more common in patients without improvement of headache [9/24 (38%)] than in controls [7/69 (10%)], p <0.01. An ACE score > 4 was more common in patients who did not improve [7/24 (29%)] than in patients who had improved more that 50% , and more common than in controls .Adverse childhood experience seems to be more common in patients with chronic headache than in controls, and most common in patients with a poor response to withdrawal therapy.No conflict of interest.


Migraine is the 3rd most prevalent and 7th leading cause of disability worldwide. India, where the prevalence of migraine is unknown, is the 2nd most populous country in the world.To estimate the prevalence and disability burden attributed to migraine in Karnataka, South India.Ethics approval and informed consent from participants were obtained. Trained interviewers selected households by random cluster sampling in urban  and rural  populations. They called unannounced at each and interviewed one adult randomly per household using a modified HARDSHIP questionnaire. Migraine was diagnosed algorithmically applying ICHD-II criteria. Disability was assessed as lost productive time by HALT index.Age-standardized 1-year prevalence was 25.2% . Point prevalence (headache yesterday) was 2.7%. Prevalence was greater among females  and in rural areas . Prevalence peaked between 35-45 years in both genders. Median frequency was 24 days/year, with a sizeable minority (6.6%) reporting >60 days/year. Headache intensity was severe in 40%. Lost productive time correlated with attack frequency. The overall mean total was 3.7 ±6.1 days/3 months, representing a loss of 6.1% of productive days, of which 2.1 ±4.0 days/3 months were lost at home and 1.4 ±4.1 days/months were lost in the work place. Disability was higher among women and in rural areas.Migraine is highly prevalent in this part of India, and associated with substantial disability, especially among women and rural populations.No conflict of interest.


Overweight and underweight increase the risk of metabolic impairments and chronic disease. Interventions at the household level require the diagnosis of nutritional status among family members. The aim of this study was to describe the prevalence and patterns of various anthropometric typologies over a decade in Colombia using a novel approach that considers all children in the household as well as the mother. This approach also allows identifying a dual burden of malnutrition within a household, where one child may be overweight and another one undernourished.This study used data from the Demographic and Health Survey and the Colombian National Nutrition Survey .normal, undernourished, overweight/obese, and dual burden - were created. Anthropometric information of height-for-age Z-scores (HAZ) and body-mass-index-for-age Z-scores (BMIz) in children under the age of 5 y, and on body mass index (BMI) in mothers, 18–49 y was used.Four mutually exclusive household (HH) anthropometric typologies - p < 0.05), while undernourished and dual burden HHs significantly decreased between 2005  and 2010  (p < 0.05). A greater increase of overweight/obesity was observed for the lowest quintile of wealth index (WI), with an increase of almost 10% between 2000 and 2010, compared to 2% and 4% for the fourth and highest WI, respectively. Although in 2010 there is still a higher prevalence of overweight/obesity HHs in urban areas (43.7%), the prevalence of overweight/obesity HHs in rural areas increased sharply between 2000 (34.3%) and 2010 (41.6%) (p < 0.05).Prevalence of overweight/obese HHs increased between 2000 (38.2%) and 2010 (43.1%)  contains supplementary material, which is available to authorized users. Adult obesity is ranked among the top ten leading attributable risk factors of mortality in Latin American countries . SimilarBoth underweight and overweight have devastating consequences for future health affecting the individual and society -5. In thA growing prevalence of overweight among disadvantaged populations has been reported in Brazil and Mexico -23. It idepartamentos in Colombia.Using data from the 2000, 2005, and 2010 Colombian Demographic and Health Survey (ENDS) and 2005–2010 National Nutrition Survey (ENSIN), which were conducted concomitantly in the years 2005 and 2010 -33, thisWe conducted a secondary data analysis of three cross-sectional, nationally representative samples  from Colombia -33. In 2Households were used as the unit of analysis using individual measures to create the HH typologies, after merging relevant information from separate ENDS/ENSIN data sets  . For theDuring ENDS/ENSIN -33 weighFour mutually exclusive categories describing household anthropometric typologies were developed based on children’s and maternal nutritional status Table .Table 1Nutritional status of children: HAZ and body-mass-index-for-age Z-scores (BMIz) in children were calculated according to the WHO guidelines  using th2), normal (BMI 18.5 – 24.9 kg/m2), and overweight/obese (BMI ≥ 25 kg/m2).Nutritional status of mother: Body Mass Index (BMI) was calculated and classified using the following WHO cutoff points : underweTaking into account all possible combinations of the anthropometric indicators used in this study, nineteen different typologies were identified Table . HoweverNormal Households: No stunting or obesity among any of the children and mother with normal BMI.2) or underweight (BMI <18.5 kg/m2).Undernourished Households: At least one child is stunted (HAZ < −2) and the remaining children are either stunted or normal and mother classified as normal (BMI 18.5 – 24.9 kg/m2) or overweight/obese (BMI > 25 kg/m2).Overweight/obese Households: At least one child is overweight/obese (BMIz > 2SD) and the remaining children are either overweight/obese or normal and mother classified as normal (BMI 18.5 – 24.9 kg/m2) or overweight/obese (BMI > 25 kg/m2) or at least one child is overweight/obese (BMIz > 2SD) and the remaining children can be either normal, overweight/obese, or stunted and overweight/obese. If the mother was classified as underweight and at least one child was stunted and the remaining children were normal, this household was included in the underweight typology. The only case in which this home was classified as dual burden was if any of the remaining children was overweight/obese or stunted and overweight/obese. The same was applicable for homes in which the mother was overweight/obese and at least one child was overweight/obese; they were only included in the dual burden typology if the remaining children were either stunted or stunted and overweight/obese.Dual Burden Households: At least one child is stunted (HAZ < −2) and the remaining children can be stunted, normal, overweight/obese, or stunted and overweight/obese (BMIz > 2SD) and mother classified as underweight  among mothers ages 18 to 49 years, was 3.9%, 95% CI: 3.5%-4.6%, 4.7%, 95% CI: 4.3%-5.1%, and 3.9%, 95% CI: 3.1%-4.2% in 2000, 2005, and 2010, respectively (p-test for trend >0.05). Meanwhile, prevalence of overweight/obesity among mothers (BMI ≥ 25 kg/m2) was 42.1%, 95% CI: 41.2%-43.5%, 41.1% 95% CI: 40%-42.5%, and 46.8%, 95% CI: 45.7%-47% in 2000, 2005 and 2010, respectively (p-test for trend <0.05). Significant differences in the average BMI of mothers were detected  (p-test for trend <0.05).Overall, prevalence of stunting (HAZ < −2 SD) among children younger than five years was 18.5%, 95% CI: 17.2%-19.2%, 16.3%, 95% CI: 15.3%-17.1%, and 14.9%, 95% CI: 13%-15.6%, in 2000, 2005 and 2010, respectively (data not shown) (p-test for trend <0.05). Prevalence of overweight/obesity (BMIz > 2SD) among children was 5.7%, 95% CI: 5.3%-6.1% in 2000, 4.5%, 95% CI: 3.2%-5.1% in 2005, and 5.2%, 95 CI: 4.3%-6.2% in 2010 (p-test for trend >0.05). Prevalence of underweight  to 2010     is marked by poverty and inequalities, as well the effects of a long lasting armed internal conflict which is higher than the burden experienced from these problems in other regions of the country . EffectsSome limitations of this study deserve mention. First, the use of secondary data brings the usual problems associated with this type of data, including the inability to obtain additional information directly from the respondents. Much of the information used in this study was self-reported and could be affected by social desirability bias . Other tStrengths of this study include the use of large national nutrition surveys that span a decade, providing rich information that allows producing a nutritional profile of the Colombian population through a period of profound economic, political and social changes. In addition, the new household classification system of anthropometric typologies developed in this study is an advancement over traditional methods since it allows the inclusion of all the children in the household and also of concomitant types of malnutrition including chronic undernutrition, overweight/obesity and dual burden at the individual level. This is the major innovation of the study and can have vast potential for assessing the population at the national level and for better targeting nutrition interventions and policies. Using information from publicly available data from Demographic and Health Surveys, it is possible for other countries from Latin America to assess the household level prevalence of malnutrition using this novel classification system. Doing so would allow for comparative studies throughout the region and establishing the prevalence of the dual burden of malnutrition at the household level, a phenomenon that still needs to be assessed and explored in some countries from the region.Colombia is in the midst of a nutrition transition that is mirroring the changes occurring elsewhere in the world, such as an increase in the overweight/obese population and a general decrease in its chronically undernourished population. In general, some homogeneity in the distribution of anthropometric typologies by WI and area of residence  was observed in this study. Although overweight/obesity continues to be more prevalent in urban versus rural areas, the rate of growth is higher among rural versus urban populations. Similar trends are seen for WI. While overweight/obesity increased with WI across all three years, a higher increase of overweight was observed for the lowest category of WI. A concerning finding documented in this study are the large regional inequalities in the prevalence of undernourished and dual burden HHs (Additional file


Cholangiocarcinoma is an invasive biliary malignancy with poor prognosis. Diagnostic accuracy of conventional methods is low which is mainly due to the specific anatomy of the disease. The aim of this study was to evaluate the diagnostic value of biochemical profile and tumor marker of the bile in patients with malignant cholestasis compared to that of choledocholithiasis.In this cross-sectional study, 46 patients with extrahepatic cholestasis were enrolled  A definitive diagnosis of cholangiocarcinoma was made by imaging, cytology and biopsy. Bile fluid was obtained by aspiration through endoscopic retrograde cholagiopantreatography (ERCP) catheter or percutaneous drainage in patients with choledocolithiasis and cholangiocarcinoma respectively. Sex and age were matched in two groups. Data regarding the biochemical profile , cholesterol, billirubin and HDL) and CA19.9 level of the bile fluid were collected, then using the SPSS software, the data were analyzed.Bile fluid level of TG, cholesterol, high – density lipoprotein (HDL), direct bilirubin and CA19.9 were significantly higher in patients with benign cholestasis in comparison with malignant cholestasis . Our study showed that the CA19.9 level of bile fluid in extrahepatic cholestasis due to biliary stone was significantly higher than those with cholangiocarcinoma, as is the biliary level of TG, cholesterol, high-density lipoprotein (HDL) and direct bilirubin. Thus they may help in the differentiation of benign versus malignant extra hepatic cholestasis. Chlangiocarcinomas arise from the epithelial cells of the bile ducts. These cancers are highly lethal because mostly are locally advanced at presentation. Due to the specific anatomy of the disease, access to the tumor for tissue sampling is difficult and imaging methods such as endoscopic retrograde chollangiopanereatography (ERCP) with brushing have less than 50% yield at the best , twenty patients diagnosed with cholangiocarcinoma were enrolled in this study, then these patients were compared with a control group of 26 patients with choledocholithiasis and symptoms of cholangitis undergoing endoscopic therapy for stone removal. The patients with pancreatic cancer were excluded from the study. This study was approved by the Ethics Committee of Babol University of Medical Sciences, an informed consent was taken from all patients before the study. In patients with cholangiocarcinoma, 10 cc of bile fluid was obtained during percutaneous bile drainage while inserting drainage catheter for palliative therapy and in patients with choledocolithiasis, 10 cc of bile fluid was collected through ERCP catheter during common bile duct (CBD). cannulation. The collected bile sample was then sent to the hospital laboratory department for storage and future analysis of the biochemical and molecular markers. The variables studied were triglyceride (TG), cholesterol (Chol), high density lipoprotein (HDL), total and direct bilirubin levels (T Bil and D Bil) and CA19.9.For the evaluation of the biochemical variable photometric method was used  and for assessing the CA19.9 of bile, Elisa method was used . All the patients’ blood was taken for serum level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AlkPhos) and bilirubin (bili) for comparison. Then we compared the demographic and biochemical variables of bile fluid in two groups. Chi-Square test was used for categorical variables and t-test or Mann-Whitney U-test for continuous variables, SPSS (Windows 16) was used for statistical analysis, p-value of less than 0.05 was considered significant. For the evaluation of sensitivity and specificity, ROC curve was used.A total of 20 patients with cholangiocarcinoma (group 1) were compared with 26 patients with choledocolithiasis (group 2). Twelve (65%) of patients in group 1 and 14 patients (52.8 %) in group 2 were men (P=0.44). The mean age of patients in group 1 was 66±10 years and the mean age of patients with choledocolithiasis was 55.1±18 years, (P=0.07). Serum ALT and AST levels were higher in group 2 while alkaline phosphatase (ALP) and total bilirubin levels were higher in group 1, respectively. Blood level of direct bilirubin was significantly higher in group 2, however . Bile flThe concentration of TG, cholesterol, HDL, direct bilirubin and CA19.9 was significantly higher in patients with gall stone compared with those who had cholangiocarcinoma. Our study showed that bile fluid TG and cholesterol were higher in subjects with choledocolithiasis in comparison with malignant obstruction of bile duct. Mean TG concentration of bile fluid was 43.5±5.4 mg/dl and 21.4±2.1 mg/dl (P<0.001) in subjects with biliary stone and cholangiocarcinoma, respectively. TG level above 29.5 mg/dl showed 69% sensitivity, 90% specificity, 90% PPV and 69% NPV for stone-induced cholestasis. Bile cholesterol concentration was 58.4±7.6 mg/dl and 28.9±5 mg/dl (P<0.001) in patients with choledocolithiasis and cholangiocarcinoma, respectively. Bile fluid total cholesterol level above 18.5 mg/dl showed 92% sensitivity, 30% specificity, 63% PPV and 75% NPV for stone-induced cholestasis. The HDL concentration of bile was 27.4±3.1 mg/dl and 6.8±0.8 mg/dl (P<0.001) in patients with bile duct stone and cholangiocarcinoma, respectively. An HDL level above 9 mg/dl had 96% sensitivity, 80% specificity, 86% PPV and 94% NPV for the diagnosis of stone-induced cholestasis.There are few studies concentrating on lipid component composition of bile. Gustafsson et al. performed a study on total lipid component of bile in subjects with and without gall stones, they found elevated cholesterol levels in patients with gall stones. Total lipid  levels was 9±0.4mg/dl and 12.9±0.5 mg/dl in those with and without gall stones, respectively which is statistically significant, but cholesterol level of bile was 7.8±0.2 mol % and 5.4±0.2 mol% in those with and without gall stones, respectively . But the difference in the level of direct bilirubin was statistically significant which was 2.8±1.1 mg/dl in cholangiocarcinoma and 7.5±1.3 mg/dl in gall stone group (P=0.012). A direct bilirubin level of the bile fluid above 6.45 mg/dl had 46% sensitivity, 95% specificity, 92% PPV and 57% NPV for the diagnosis of stone induced cholestasis. In normal state the main bilirubin of bile fluid is direct bilirubin, the proposed reason for the difference seen in patients with bile duct cancer is that chronic cholestasis may alter the conjugation capacity of hepatocytes.In our study, we analyzed the serum level of AST, ALT, and ALP in two groups. We found higher level of transaminases in patients with choledocolithiasis, in stone-induced obstruction an acute elevation of the intrahepatic bile duct pressure is produced that leads to abrupt elevation of transaminases but in malignant biliary obstruction, this elevation is blunted and high concentration of transaminases is not seen.Serum level of AlkPhos was higher in patients with malignant obstruction as was the level of total and direct serum bilirubin. Qin et al. found a higher level of serum ALP in those with malignant biliary tract disease versus benign biliary tract disease, but the serum level of AST was higher in patients with malignant biliary disease in their study which is in contrast with our study .In our study, bile fluid level of CA19.9 was 325±88 U/ml in patients with cholangiocarcinoma and 905±421 U/ml in those with stone-induced cholestasis (P= 0.03). CA19.9 level above 111 U/ml had 100% sensitivity, 40% specificity, 17% PPV and 83% NPV for the diagnosis of stone-induced biliary obstruction. Akdogan et al. in a study which was done on the serum and bile fluid level of CA19.9 in patients with malignant and stone induced biliary obstruction found a mean bile fluid CA19.9 level of 14000 and 14818 U/ml in those with malignant and stone-induced biliary obstruction, respectively (P=0.8). The serum CA19.9 level was higher in malignant group in their study, however . The samIn Ohshio et al.’s study there was no significant difference in the bile fluid CA19.9 level between those with malignant compared to non-malignant disease . PeterliIn conclusion, we showed that the measurement of bile fluid lipid profile especially TG , HDL and its direct bilirubin and CA 19.9 level may be a useful complementary test in differentiation between benign and malignant cholestasis.


The karyotype represents one of the main cornerstones for the International Prognostic Scoring System (IPSS) and the revised IPSS-R (IPSS-R) that are most widely used for prognostication in patients with myelodysplastic syndromes (MDS). The most frequent cytogenetic abnormalities in MDS, i.e. del(5q), -7/del(7q), +8, complex karyotypes, or −Y have been extensively explored for their prognostic impact. The IPSS-R also considers some less frequent abnormalities such as del(11q), isochromosome 17, +19, or 3q abnormalities. However, more than 600 different cytogenetic categories had been identified in a previous MDS study. This review aims to focus interest on selected rare cytogenetic abnormalities in patients with MDS. Examples are numerical gains of the chromosomes 11 (indicating rapid progression), of chromosome 14 or 14q , -X , or numerical abnormalities of chromosome 21. Structural abnormalities are also considered, e.g. del(13q) that is associated with bone marrow failure syndromes and favorable response to immunosuppressive therapy. These and other rare cytogenetic abnormalities should be integrated into existing prognostication systems such as the IPSS-R. However, due to the very low number of cases, this is clearly dependent on international collaboration. Hopefully, this article will help to inaugurate this process. Some less frequent isolated cytogenetic abnormalities have been characterized for their impact on prognosis such as del11q) (very good prognosis), isochromosome 17q or +19 (intermediate prognosis), or inv3/t(3q)/del(3q) (poor prognosis).1q very  in patieIn general, most frequent in MDS are cytogenetic losses resulting from monosomies or deletions, mostly involving chromosomes 5, 7, 20 or Y. The gain of genetic material with the occurrence of total or partial trisomies  is less frequent. Unbalanced translocations may also cause losses or gains of genetic material. Different from AML balanced structural abnormalities occur only rarely in MDS. Some of the most important rare cytogenetic abnormalities in MDS are discussed in detail in the following, focusing on their frequency, their diagnostic meaning, their molecular background or associations and their impact on the prognosis according to the literature and own findings.Acquired non-constitutional loss of a sex chromosome  is an age-related phenomenon, but can also occur in association with hematological malignancies.22By FISH a suitable probe for the detection of the sex chromosomes is easily available and can be performed on different samples .RB1 gene that had been first identified in patients with retinoblastomaRB1 gene is a tumor suppressor gene that is involved in cell-cycle control and in the process of cell differentiation.RB1 is a useful adjunct to cytogenetics when abnormalities of 13q14 are detected.27Deletion of 13q occurs in different hematological malignancies, i.e. in lymphatic malignancies such as chronic lymphocytic leukemia (CLL) or multiple myeloma, but may also be observed in myeloid malignancies such as chronic myeloid leukemia (CML), myeloproliferative neoplasms (MPNs), or MDS . The RB1et al. investigated 22 patients showing bone marrow failure with a sole del(13q) or with a del(13q) and additional cytogenetic abnormalities. All del(13q) patients were diagnosed with MDS-U. PNH clones were detected in 19 patients. Strikingly, all 14 patients with del(13q) alone and 2 of 5 patients with additional cytogenetic abnormalities responded well to immunosuppressive therapy with favorable 10-year OS rates of 83% and 67%. Only two patients with additional cytogenetic abnormalities developed s-AML.et al. analyzed 86 patients with aplastic anemia (AA) with available cytogenetic results. Six patients (7%) showed a del(13q). All but one of these patients showed evidence of PNH clones. Also in this series, there was a favorable response to immunosuppressive therapy and all patients but one were still alive after a median follow-up of 105 months. None of the patients with del(13q) developed leukemic transformation. Thus, the patients with bone marrow failure and del(13q) from both cohorts  showed similar characteristics and outcomes. These reports suggest that MDS-U with del(13q) may be seen as an overlap condition between MDS and AA.It has been suggested that unclassified MDS (MDS-U) with del(13q) was a benign bone marrow failure subset characterized by good response to immunosuppressive therapy and a high prevalence of PNH clones.et al..et al., the median hemoglobin level was 7.2 g/dl, the median platelet count was 35/nl and the median ANC count 2.2/nl, respectively. The median bone marrow blast count was 13%.32Monosomy 21 (-21) as a sole abnormality is rare in primary MDS with a frequency of 0.3%.et al.33Isolated trisomy 11 (+11) is a very rare abnormality in MDS. The frequency was described between 0.2 and 0.3% of all MDS cases.et al.de novo AML and 4 patients with s-AML following MDS who showed a median OS of 5 months and an aggressive course of the disease. Obviously, +11 does not show any specific association to a certain WHO (WHO) or FAB MDS subtype or secondary or therapy-related MDS.33Trisomy 11 can also occur in patients with AML. MDS and AML patients with +11 were reported to show early stem cell features with a low degree of maturation.MLL gene on 11q23.MLL partial tandem duplications (MLL-PTDs).FLT3-ITD mutation.38Trisomy 11 affects the Because of the very low frequency of isolated +11 in MDS, it was so far assigned to the intermediate risk category according to the IPSS and the IPSS-R, respectively.de novo acute leukemia being observed in 8/621 (1.3%) consecutive patients . The survival of these patients was poor with a median of 9.5 months (range: 0.5 to 14.7 months).FLT3 overexpression and cooperating RUNX1 mutations.46Trisomy 13 (+13), especially as solitary abnormality, is very rare, however it has been observed recurrently in myeloid neoplasia, mostly in AML, primary myelofibrosis, atypical CML and MDS.In a large series published by the Mayo Clinic in Rochester +13 was detected in 0.2% (n=9) of all MDS and 0.7% (n=15) of all AML patients. Furthermore one patient with primary myelofibrosis, one with CMML and one with pernicious anemia had +13, too. There was a clear gender imbalance with 21/27 males. The median age was 73 years. In 96% of these cases, +13 was isolated. In the 9 MDS cases, the majority showed blast increase and disgranulopoiesis with hypogranulation. Furthermore, 6/9 patients showed small monolobated megakaryocytes remembering the situation in del(5q) MDS. Two patients with higher risk MDS were treated with hypomethylating agents but did not respond. Blood values (medians) for the whole +13 cohort were Hb = 9.0 g/dl (6.2–13), leukocytes = 5.3/nl (1.0–264.8) and platelets = 87/nl (11–312). The whole trisomy 13 cohort (summarizing the MDS and AML patients) revealed a median survival of 5.8 months (range: 0.5 – 24).48FLT3 located at the triplicated chromosome. Furthermore, there is a close association between +13 and mutations of RUNX1.In conclusion, +13 is a very rare condition in MDS, occurring in 0.2 to 0.8% of patients, mostly as an isolated change. In AML +13 is a bit more frequent with an incidence between 1 and 2%. The majority of patients have isolated +13. Most patients are over 70 years old and are males. Typically, the MDS is advanced with blast excess and moderate pancytopenia. Although most survival data relate to AML cases, the prognosis is bad with median survival ranging between less than six months and one year. Patients with AML and +13 do not respond to standard intensive chemotherapy, and hypomethylating agents for MDS patients also might be inefficient although database is not satisfying concerning this issue. However, high-dose lenalidomide could be an option. On a molecular level, +13 is associated with an overexpression of Trisomy 14, in general, is extremely rare in hematologic malignancies but shows a clear association with myeloid neoplasia.In a multicenter cytogenetic study we observed +14 in 3 (0.1%) patients, with one additional abnormality in 4 (0.2%) and in 9 (0.4%) patients with complex changes out of 2,072 patients of the entire cohort.Hematologic findings in patients with trisomy 14/14q are inconsistent. Mancini reported a tendency to normal or increased platelets while in the case collection of Cui patients with MDS showed a broad range of platelet levels . Remarkably thrombocytosis was only observed in 2 RARS cases, whereas in the remaining five MDS cases (4 RAEB-1/-2 and 1 RCMD) platelets were low to normal . Patients with CMML showed normal to increased platelet counts . Hb values ranged between 4.0 g/dl and 12.0 g/dl (median 9.8 g/dl) in the review of Mancini with comparable data (median 10.0 g/dl) in the series of Cui.et al. who reported a median survival of 28 months in MDS, 31.5 months in MDS/MPN and nine months in AML.50In a literature review, survival data from 18 patients suggest an intermediate prognosis.KIT, RAS, FLT3, NPM1, JAK2) in this cytogenetic subgroup identified FLT3-ITD in 1/6 MDS at diagnosis later transforming to s-AML and KRAS-mutation in 1/7 MDS patients at the time of leukemic transformation. Thus, the molecular background in these cases remains to be clarified.The only systematic molecular investigation  is well known in the context of Down’s syndrome, associated with a marked risk to develop AML during childhood. However, besides this hereditary disease, +21 may also occur as a clonal somatic abnormality in several hematologic disorders. In adult RUNX1 (=AML1), located on chromosome 8q22, commonly involved in t/RUNX1-RUNXT1 in AML, was shown to be also point mutated in patients with myeloid malignancies like AML, MDS and MPN with +21.RUNX1 mutations in MDS but did not describe a correlation with +21.56The molecular background of patients showing +21 in myeloid malignancies remains undefined as yet. et al.57Gain of 1q resulting in complete or partial trisomy 1q can be due to duplications, to the formation of an isochromosome i(1q), to the gain of a deleted or a whole chromosome, or to unbalanced translocations with different partner chromosomes as demonstrated in an MDS case series presented by Fonatsch Isochromosome 1q [i(1q)] may occur in different hematological malignancies such as ALL or lymphoproliferative disorders, or in solid tumors.et al. reported on a male patient developing t-MDS with isolated i(1q) 14 years after therapy of acute promyelocytic leukemia (APL). There was no blast increase, and the t-MDS showed only slow progression under supportive therapy.de novo MDS, e.g. a 20-year-old female patient with a hypocellular bone marrow who received allogeneic HSCT.et al. reported on a 24 years old male patient with RAEB-T and isolated i(1q) who remained clinically stable over ten months.Duplication of 1q mainly occurs as a secondary event in MDS. Occasionally, dup(1)(q21q32) has been documented as a sole cytogenetic abnormality in MDS patients. Alfaro et al. reported on two MDS patients with a sole dup(1)(q21q32). One patient showed a clonal cytogenetic evolution with an additional +8; the other patient evolved to s-AML.unbalanced translocations may lead to a gain of 1q. Derivative translocation der was described mostly in patients with AML, but also in patients with CML, MPNs, or MDS. The breakpoints of der vary from 1q11 to 1q43, with a clustering to 1q21-23, and the 5q breaks occurred in 5q11 to 5q35, with preponderance in the distal 5q3 region. Derivative translocation der was either reported as isolated abnormality or in combination with other cytogenetic abnormalities.et al. suggested that the prognostic impact of the respective abnormality was poor as most patients included in this report had died.et al. summarized several MDS cases with der(1) from the literature. Male preponderance was evident. Patients showed different MDS subtypes with or without blast increase, but a high transformation rate to s-AML was noted in 4 out of 7 patients. As shown by FISH analyzes, the respective translocation was resulting in a gain of 1q and loss of 16q.57Furthermore, various per se.et al. came to the conclusion that MDS with 1q involvement shows a poor outcome when compared with the overall series of patients. However, due to the rare occurrence of this abnormality the authors recommended caution with regards to this interpretation.54Hypothetically, the major consequence of these unbalanced translocations is the chromosomal imbalance resulting from the gain of the long arm of chromosome 1q and the loss of genetic material from the partner chromosome rather than the chromosomal break der(7)t that represents an unbalanced whole-arm translocation between the centromere-near regions of 7p and 1q and results in unbalanced gain of 1q and loss of 7q  positive MDS patients with patients with chromosome 7 abnormalities  and found no significant differences with regard to leukemic transformation rate or 5-year survival between these different cytogenetic risk groups.et al. retrospectively compared a cohort of 77 patients suffering from different myeloid malignancies  all carrying der with patients with -7 or 7q. The MDS patients with a der showed significantly lower blast counts, higher hemoglobin levels, and slower progression to s-AML as compared with the cases carrying other chromosome 7 abnormalities.et al. documented frequent occurrence of previous chemo- or radiotherapy or additional cytogenetic changes in patients with MDS or AML with der.et al. described an increased frequency of isocitrate dehydrogenase (IDH1 and IDH2) mutations in t-MDS/AML patients with der and other +1q abnormalities.68A poor prognostic impact and a high risk of transformation to s-AML has been described in MDS patients carrying der. Slovak MLL gene, are frequent in adult and pediatric acute lymphoblastic and myeloid leukemia. Rearrangements of the MLL gene with several partner genes result in various effects on hematopoietic stem cells, especially differentiation anomalies. Actually, more than 70 translocation partners have been identified.MLL gene may also be affected by partial tandem duplications (MLL-PTDs). 11q23/MLL translocations are seen in around 22% of patients with ALL which is much more frequent as compared to AML with only 5% of patients being affected.MLL translocations are strongly associated with a previous exposition to topoisomerase-II inhibitors (e.g. etoposide).MLL translocations suffer from myelodysplastic syndromes.MLL translocations are very rare in primary MDS and can be found in 0.5% of patients as part of a non-complex karyotype.MLL translocations as sole aberrations in MDS is even lower with 0.2% of all patients.MLL translocations are correlated with the WHO subtypes RA or RAEB-1.MLL translocations described by Schanz et al., these abnormalities were associated with a low hemoglobin level (7.9 g/dl) but a normal platelet (140/nl) and ANC (6.3/nl) count. The median bone marrow blast count in these seven patients was 4.0%. A higher frequency of 11q23/MLL translocations was described by Solé et al. in a study based on 968 patients with MDS. In this cohort, sole 11q23/MLL translocations were described in 6% of patients.Reciprocal translocations of 11q23, involving the MLL translocations in MDS, Solé et al. found a median OS of 26 months and a cumulative risk for developing acute leukemia of 40% to 1 year and 92% to 5 years,MLL translocations. In another study, the median OS of patients with 11q23/MLL translocations occurring within a non-complex karyotypes was 20 months.MLL translocations in MDS, their real prognostic impact is not well defined for this hematologic entity. Consequently, as other rare single abnormalities, 11q23/MLL translocations were assigned to the intermediate risk group in the IPSS and also in the IPSS-R.39Regarding the prognostic impact of 11q23/MLL translocations are associated with an intermediate prognosis. Trisomy 14 is prognostically intermediate to favorable.7Due to the missing statistical validity caused by the low number of cases, rare cytogenetic abnormalities that are not considered specifically by the IPSS-R are assigned to the prognostically intermediate cytogenetic subgroupFinally, our working group would like to emphasize our interest in collecting additional cases with rare cytogenetic abnormalities with the aim to expand our database, to increase insights in the cytogenetic complexity of myelodysplastic syndromes, and to promote the exchange between hematologists interested in this issue.