Aims: To outline the different characteristics of glaucomas and to determine the risk factors and their consequences on postoperative visual acuity, intraocular pressure (IOP), and inflammation, including corneal changes and optic disk changes.Settings and designs: Longitudinal prospective study done over a period of 1.5 years in a medical college hospital.Materials and methods: Fifty patients of lens-induced glaucoma (LIG) were included. At presentation, visual acuity, IOP, and inflammation, including corneal changes, were recorded. After medical line of treatment, postoperatively patients were followed up regularly at 2 and 7 weeks interval and the same parameters were evaluated including optic disk changes.Statistical analysis used: Paired t-test, chi-square test wherever applicable with p-value < 0.05 as significant.Results: The mean age of presentation was 60.68 years with female to male ratio of 1.7:1. The best corrected visual acuity(BCVA) of 6/18 or more was found in 54% cases, whereas visual acuity of less than 6/60 was seen in 26% of cases. Visual acuity of 6/12 or better was achieved in 72% (p < 0.01) of cases with symptoms less than 2 weeks and in 59.10% of cases with IOP of less than 35 mm Hg at presentation. The mean IOP in cases with duration of symptoms of 2 to 4 weeks was 40.33 ± 9.36 mm Hg. Optic disk of the affected eye suffered damage in 42% of cases and in 80% of cases with symptoms for more than 2 weeks.Conclusion: Early diagnosis and treatment is beneficial in LIG cases.How to cite this article: Sharanabasamma M, Vaibhav K. Management and Visual Outcome in Patients of Lens-induced Glaucomas at a Tertiary Eye Care Hospital in South India. J Curr Glaucoma Pract 2016;10(2):68-75. These are heterogeneous group of disorders which develop through either open-angle or angle-closure mechanisms.3 Phacolytic glaucoma (PLG) and lens particle glaucoma are types of secondary open-angle glaucomas. The angle of anterior chamber is open with blockage of the trabecular meshwork by lens proteins. Phacomorphic glaucoma (PMG) and lens displacement glaucoma are types of secondary angle-closure glaucomas. Phacoanaphylactic uveitis, now termed as lens-induced uveitis, is not truly an anaphylactic reaction but is a granulomatous reaction that can cause open-angle or angle-closure glaucoma or combined open-angle and angle-closure glaucoma.4In India, 62.6% blindness is due to cataract.5 Numerous studies have been done, which have determined and described the characteristics, risk factors, and causes for visual outcome and intraocular pressure (IOP) in LIG; also appropriate medical and surgical line of management have been formulated. Nevertheless, there are scanty reports and studies on the inflammation and its consequences in LIGs.There are various social, economic barriers for the people in our country for accessing excellent surgical services even these days. Whatever be the mode of surgical intervention, the prognosis for good postoperative visual recovery in these conditions remains guarded, unless diagnosed early and managed efficiently.The present study has endeavored to determine the characteristics, risk factors, and their effects on postoperative visual outcome, inflammation, IOP including corneal changes and optic disk changes in LIGs.Prospective type of study was done, which included 50 cases of different types of LIG, admitted in the ophthalmic wards of a medical college hospital from November 2011 to April 2013 after obtaining the Institutional Ethical Committee clearance. All patients who were diagnosed having LIG Patients who signed written and informed consent for the surgery and also for the study were included. Primary glaucoma Secondary glaucoma other than LIG Patients with poor general condition which made them unfit for surgery.All patients diagnosed as LIG based on clinical symptoms and signs were included. Clinical features included pain, loss of vision, redness of the eye, headache, presence of an intumescent, mature or hyperma-ture cataract associated with raised IOP of more than 21 mm Hg.A detailed clinical examination of both eyes included the status of the lens, depth of the anterior chamber by slit lamp biomicroscopy, and IOP recording by Perkins applanation tonometry, the values of which are comparable to Goldmann applanation tonometry. Based on the slit lamp examination, the type of LIG was determined. After patients signed the written and informed consent, the clinical features were noted in the study. At presentation, visual acuity, IOP, inflammation including corneal changes were recorded, which were again repeated after medical treatment. None of the cases had fundal glow at presentation.The diagnosis of PMG was made in patients having redness of eye, with acute onset of pain and reduction of vision of certain duration. On clinical examination the eye showed circumcorneal congestion, corneal edema, shallow anterior chamber, dilated and fixed or sluggish pupil, intumescent cataract, and IOP more than 21 mm Hg.Phacolytic glaucoma was diagnosed when patients presented with acute pain in the eye with long-standing poor vision. On examination, the eye showed marked diminution of vision, corneal edema, normal or deep anterior chamber containing floating lens particles, and/or with pseudohypopyon in severe cases, and hypermature morgagnian cataractous lens in few cases. Diffuse keratic precipitates and intense flare were seen.The aim of treatment for these cases was to preserve useful vision, relief from pain, and reduction of the elevated ocular tension to almost normal levels, which was achieved by both medical and surgical methods. Analgesia was achieved by lowering down the IOP and by systemic administration of analgesics. Antiemetics were given in cases of severe vomiting.In all cases, preoperative medication to reduce IOP included either topical timolol 0.5% twice a day, oral acetazolamide 500 mg thrice a day, or intravenous man-nitol 20% alone or in combination, and also intravenous mannitol 20% was used before the surgery in refractory cases. Topical phenylephrine 10% was used just before surgery to achieve mydriasis so as to facilitate adequate capsulorhexis. Moxifloxacin eye drops were instilled in all the cases three times per day from the time of admission till the day of surgery as a prophylactic measure to make the conjunctival sac sterile. Systemic, oral ciprofloxacin (500 mg) 12 hourly was given as prophylaxis to prevent postoperative infection as intracameral antibiotics were not used.In all patients, cataract extraction with intraocular lens (IOL) implantation was offered under guarded prognosis. Irrespective of the level of fall of tension, all the patients were taken for surgery either on same day or on following day, depending upon patient’s condition. In all the patients, after peribulbar block, digital pressure was applied except in lens displacement cases, for nearly 8 to 10 minutes to achieve good hypotony. Planned manual small-incision cataract surgery (SICS) with IOL implantation was done in all but except in one case. In one case, after lens extraction IOL was not implanted, since the patient had posterior capsule tear, which needed an experienced vitreoretinal surgeon. Thorough anterior chamber wash with normal saline was given. At the end of the procedure, subconjunctival injection of steroid and antibiotic was given.Postoperatively in the ward, all the patients received topical antibiotic - steroid combination - 1 drop hourly a day was given for mydriatic-cycloplegic effects, or twice a day if required. If severe uveal inflammation was present, then oral prednisolone 1 mg/kg body weight was given in a tapering dose over 3 weeks. If the tension was above 20 mm Hg, topical timolol 0.5% twice daily were instilled and in cases where tension was above 25 mm Hg, oral acetazolamide or IV mannitol 20% was given depending on the severity.All the subjects were followed up regularly at day 1, day 14, and day 49. At every visit, patients were evaluated for visual acuity with Snellen’s chart, IOP by Perkins applanation tonometer, slit lamp examination of anterior segment, and posterior pole examination with direct ophthalmoscope and 90D lens.The results were tabulated on Microsoft excel spreadsheet and the data was statistically analyzed using various tests, such as, paired t-test, chi-square test, and pooled chi-square test wherever applicable and a p-value of < 0.05 was considered significant.A total of 50 patients were included in the study. The age range was 46 to 75 years with a mean of 60.68 ± 6.65 years. The ratio between female and male was 1.7:1, with mean age of 60.41 ± 5.97 years in females and 61.17 ± 7.88 years among males. p-value is 0.237 which is not statistically significant. The most frequent age group among both males and females was 60 to 69 years. Phacomorphic glaucoma was the most common LIG with 43 cases (86%), followed by PLG with 7 cases (14%) .In this study, the mean duration of symptoms was 18.98 ± 16.22. The mean duration of symptoms in PMG cases was 18.97 ± 16.64 days and in PLG, it was 9 ± 14.52 day, which is insignificant statistically. Of the total 50 cases , 25 (50%) presented with symptoms of more than 2 weeks and 25 (50%) presented with duration less than 2 weeks. 22 (51.16%) of 43 PMG cases and 03 (42.86%) of 7 PLG cases presented with symptoms of more than 2 weeks.No cases at presentation had visual acuity better than hand movements. At the last follow-up, 22 (44%) cases gained good visual acuity of 6/12 or better.In this study, the total mean IOP at presentation was 38.88 ± 11.31 mm Hg (22-64 mm Hg); after medication, it was 18.76 ± 3.47 mm Hg, and at the last follow-up, it was 15.60 ± 2.10 mm Hg with the use of timolol 0.5% eye drops and tablet acetazolamide 250 mg. Paired t-test was used to compare the reductions of IOP from baseline at presentation to post medication, from baseline at presentation to last follow-up, and post medication to last follow-up. The respective mean were 20.12 ± 1.41 , 23.32 ± 15.94 , and 2.78 ± 0.49 .2=5.143, degrees of freedom (DF) = 1, p ≤ 0.05].Inflammation at presentation was the most common and was mild to moderate in 32 cases (71.12%), while 12 cases had severe inflammation (26.66%). At discharge on day 3 after surgery, inflammation was reduced to mild in 22 cases (48.89%), to normal in 7 cases (15.56%), and only 4 cases had severe inflammation (08.89%). At the last follow-up on day 49, 41 cases (91.11%) were free of inflammation, none had severe inflammation, and rest had mild to moderate inflammation. The reduction of all grades of inflammation at presentation to normal on discharge was achieved in 7 (15.56%) cases, which was statistically significant [McNemar test, χA majority of 48 patients (96%) underwent SICS with posterior chamber IOL implantation followed by 1 case with additional peripheral iridotomy done. Rest 1 case underwent only SICS without posterior chamber lens implantation.In this study, a majority of 42 cases (93.34%) underwent extracapsular cataract extraction with posterior chamber IOL implantation.At the last follow-up, 29 cases (58%) had normal fundus, 13 (26%) cases had 0.4 to 0.7 cup disk ratio (CDR), and 8 cases (16%) suffered severe glaucomatous disk damage (GDD) (0.8-0.9 CDR).2 = 1.046, DF = 1, p ≥ 0.05). Poor visual outcome of less than 6/60 in both the subgroups were almost the same, with 8 (29.63%) cases in PMG and 4 (26.67%) cases in PLG  of 6/12 or better, at the last follow-up, was achieved in 10 (37.04%) cases of PMG and 8 (53.33%) cases of PLG  (The BCVA at the last follow-up of 6/12 or better was achieved in 16 (76.2%) of 21 cases with symptoms less than 2 weeks and in only 3 (12.5%) of 24 cases with symptoms of more than 2 weeks. The poor visual acuity at the last follow-up of less than 6/60 was found in 12 (50%) of 24 cases with symptoms more than 2 weeks and in 1 (04.16%) case with symptoms of less than 2 weeks. The duration of symptoms had linear relation with visual outcome. The more the duration of symptoms, the poorer the visual outcome (χ < 0.01) .2 = 1.364, DF = 1, p > 0.05).The BCVA at the last follow-up of 6/12 or better was achieved in 9 (60%) cases that presented with IOP of less than 35 mm Hg, and in 10 (33.33%) cases with presentation IOP of more than 35 mm Hg. Poor vision of less than 6/60 was seen in 4 (26.67%) cases and 9 (30%) cases, with presentation IOP of less than 35 mm Hg and more than 35 mm Hg respectively , which was statistically significant.Good visual acuity at the last follow-up of 6/12 or better was achieved in 15 (46.88%) of 32 cases with mild to moderate inflammation at presentation and in 4 (30.77%) of 13 cases with severe to very severe inflammation. Poor visual acuity of less than 6/60 at the last follow-up was seen in 4 (12.5%) of 32 cases and 9 (69.23%) of 13 cases, with mild to moderate inflammation and severe to very severe inflammation respectively. The severity of inflammation at presentation was directly proportional to the poor visual outcome (χSeventeen (77.27%) of 22 cases whose fundus was normal and 2 (12.82%) of 18 cases with GDD achieved BCVA of 6/12 or better at the last follow-up. Whereas, 10 (55.5%) of 18 cases with GDD and none of normal fundus cases had visual acuity of less than 6/60. On applying Fisher’s exact test, the poor visual acuity of less than 6/60 in cases with GDD was found to be statistically significant (p = 0.000).At presentation, the mean IOP in cases with symptoms of less than 2 weeks was 38.76 ± 12.59 mm Hg. The mean IOP with symptoms for 2 to 4 weeks was marginally high with 40.33 ± 9.36 mm Hg and significantly high in cases with symptoms of more than 30 days with 44.67 ± 14.84 mmHg.After medication, the mean IOP in cases with duration of less than 2 weeks was 22.48 ± 8.02 mm Hg. The mean duration of IOP with duration of 2 to 4 weeks was nearly equal to 22.88 ± 9.63 mm Hg and marginally high in cases with symptoms more than 30 days being 25.33 ± 13.24 mm Hg. At the last follow-up, the mean IOP with symptoms of less than 2 weeks was 14.09 ± 1.73 mm Hg and was nearly equal in cases with symptoms for 2 to 4 weeks and more than 30 days being 18.44 ± 6.98 and 18.67 ± 12.43 mm Hg respectively.The mean IOP at presentation in PMG was 40.67 ± 12.96, and 39.87 ± 10.62 mm Hg in PLG. After medication, the mean IOP was 23.37 ± 8.78 and 20.67 ± 6.91 mm Hg and at the last follow-up it was 16.67 ± 5.71 and 16.93 ± 8.07 mm Hg respectively. These differences are neither clinically nor statistically significant .2/Yc = 2.491, DF = 1, p > 0.05) and after medication  was statistically not significant  compared to PLG in 3 (20.00%) cases, which commonly presented with severe inflammation in 6 cases (40.00%) as against 5 cases (18.51%) in PMG. The inflammation reduced to normal with preoperative medication in 3 cases (11.11%) of PMG and 4 cases (26.67%) of PLG respectively. At the end of 6th week follow-up, the inflammation subsided almost to normal in 25 cases (92.50%) and 13 cases (86.66%) of PMG and PLG respectively. None of the total cases had severe inflammation at the end of last follow-up. The difference in inflammation among subgroups at presentation  (The inflammation was mild to moderate in 17 (80.95%) of 21 cases with duration of symptoms less than 2 weeks and in 15 (71.42%) of 24 cases with duration of symptoms more than 2 weeks, whereas severe to very severe inflammation was found in 4 (19.04%) of 21 cases and 9 (37.50%) of 24 cases respectively. There was statistically significant correlation between severity of inflammation and duration of symptoms (χ < 0.05) .2=9.504, DF=1, p < 0.05) (Inflammation at presentation was mild to moderate in 14 (93.33%) cases with IOP less than 35 mm Hg and in 18 (60%) cases with IOP more than 35 mm Hg. Severe to very severe inflammation was seen in 1 (6.67%) case and 12 (40%) cases with IOP less than 35 and more than 35 mm Hg respectively (χ < 0.05) .2 = 1.434, DF = 1, p > 0.05).The optic disk changes at the end of last follow-up were normal in 11 cases (40.75%) and 9 cases (60%) in PMG and PLG respectively . Mild to2=16.200, DF = 1, p < 0.01)  presented before 2 weeks and in 5 (20.83%) of 24 cases presented later than 2 weeks. Mild to moderate disk damage was found in 8 (44.45%) cases of those presented between 2 and 4 weeks and severe damage was found in 5 cases (83.33%) of those presented more than 30 days. There was statistically significant correlation between severity of damage to the disk and duration of the symptoms (χ < 0.01) .2=1.11, DF = 1, p > 0.05).Fundus changes at the last follow-up were normal in 9 cases (60%) of those presented with IOP less than 35 mm Hg, and in 13 cases (43.33%) of those presented with IOP more than 35 mm Hg. There was severe GDD in 1 case (06.67%) and 6 cases (20.00%) of those presented with IOP less than 35 mm Hg and more than 35 mm Hg respectively . The cor6Lens-induced glaucomas occur commonly in India. Though these are clinically distinct entities, they have certain common factors in that they are resultant of lens and damage the optic nerve because of high IOP with cataract surgery as definitive treatment in these cases, and finally they uniformly share a guarded prognosis.This longitudinal study was undertaken to study the management of LIG and to study the visual outcome after planned manual SICS.5In this study, the age range was 46 to 75 years with a mean age of 60.68 ± 6.65 years. Highest number of cases occurred in the age group 60 to 69 years (60%). In Lahan study, it has been found that the occurrence of LIG is in the age range of 40 to 80 years and highest in the 60 to 69 years (43.1%) age group, indicating that the LIGs are a condition of old age.6 The ratio between females and males in Lahan study was 1.7:1. It is possible that these entities are more common in females because of socioeconomic repression, and also because of the fact that cataract is more prevalent among females than males. This finding was consistent with data from the Punjab study in India and from the MATLAB study in Bangladesh.5Females had an increased risk of LIG over males with a ratio of 1.7:1 in this study, which is comparable to that of a study conducted in Madurai with female pre-ponderence (p = 0.05).Lens-induced glaucomas are either angle-closure or open-angle type, resulting due to some disorder of crystalline lens.Phacomorphic glaucoma is defined as a secondary angle-closure glaucoma due to lens intumescence. An acute rise of IOP can hamper the optic nerve function and may lead to irreversible visual loss if not treated on time.Phacolytic glaucoma is the sudden onset of open-angle glaucoma caused by a leaking mature or hypermature cataract.6 and Lahan study (72%).5 Occurrences of various LIGs in the above studies show variations. Almost always, PMG is the most common type of LIG among several studies, even the present one, which is peculiar to the developing countries. In this study, none of PMG occurred below 50 years of age, showing that PMG is a disease of old age with preponderance in 60 to 69 years age group. This may be due to the unawareness and lack of medical services in developing countries. In contrast, PLG represents lens-induced acute secondary open-angle glaucoma associated with quicker onset of pain, redness, and watering in the eye with an acute elevation of IOP, making the patient to seek medical advice earlier than PMG.The observations made in this study conclude that PMG (86%) was the most frequent type of LIG followed by PLG (14%). Similar occurrence was noted in Madurai study (52.68%)5 at Pravara Rural Hospital, Loni.7In this study, none of the cases had vision better than hand movement at presentation. In the present study, BCVA of 6/18 or better is slightly higher (54%) when compared with Lahan study series (31.40%), and much higher when compared with Pravara Rural Hospital, Loni study (16%). Thus, in this study, higher percentage of cases has achieved good visual recovery and lower percentage of cases have poor visual outcome when compared to Lahan study series6 The BCVA of 6/12 or better was taken as good visual acuity and less than 6/60 as poor visual outcome.The BCVA in this study of 6/12 or better was low (44%) and poor vision of less than 6/60 higher (26%) compared to Madurai study, with 59.13 and 11.82% respectively.6In this study, good visual acuity achieved by cases with PLG (57.14%) was more than PMG (41.86%) and this difference was clinically significant but statistically not significant (p > 0.05). Poor outcome of less than 6/60 showed no significant difference between PLG (28.57%) and PMG (25.58%). There was no statistically significant difference noted among the two groups on final postoperative visual recovery in Madurai study (p = 0.68).Good visual acuity achieved in cases presented within 2 weeks (72%) was more than the cases presented beyond 2 weeks (16%), whereas poor visual acuity of less than 6/ 60 was more in cases presented beyond 2 weeks (52%). Our study has a linear relationship between the symptom duration and BCVA at final follow-up. As there was delay in the initial presentation, the visual outcome became more guarded, which was clinically and statistically significant (p < 0.01).5The Lahan study of 1998 found that the duration of pain and high level of IOP at presentation in PMG was associated with poor visual outcome at discharge, while in PLG no such association were made out.In our setup, the patients presented late, probably because of poverty, ignorance, lack of awareness, facilities for treatment, quackery at peripheries, and lack of prompt referral and helplessness of patients would have led to increase morbidity.In this study, the influence of inflammation on final visual outcome was analyzed. Good visual acuity achieved in cases with mild to moderate (52.78%) inflammation was higher than cases with severe to very severe inflammation (21.43%). Poor vision was found to be higher in cases with severe inflammation (71.43%) than with mild to moderate inflammation (8.33%). The final visual acuity was affected by the severity of inflammation which was significant both clinically and statistically (p < 0.05).6Madurai study had found no statistically significant association between the level of preoperative IOP and final visual acuity.7 similar to that of our study. Though the mean IOP at the last follow-up was normal (16.44 ± 6.54 mm Hg), cases with delay in presentation between 2 and 4 weeks and more than 30 days tend to be on higher end of normal (18.44 ± 6.98 and 18.67 ± 12.48 mm Hg). So a delay of more than 2 weeks in presentation would result in higher IOP, notably if the delay is beyond 30 days, which is clinically significant.The IOP reduction from baseline at presentation to post medical line of treatment and to last follow-up and from medical line of treatment to last follow-up were found to be clinically and statistically significant. It is found that the reduction in mean IOP is greater after medication for glaucoma. Nevertheless, surgical removal of lens is the definite treatment for LIG and response to medications is very good in LIG. The IOP at the last follow-up was reduced to normal limits (16.44 ± 6.54 mm Hg). This indicates that in LIGs, IOP should be reduced by medical line of management prior to surgery near-normal to normal to achieve stable IOP postoperatively without any further antiglaucoma medications. Intraocular pressure tends to be higher if there is a delay in presentation beyond 30 days (44.67 ± 14.84 mm Hg) than the duration of presentation of less than 2 weeks (38.76 ± 12.59 mm Hg). The mean preoperative IOP was 46.2 mm Hg in study by Kothari et al5 Madurai study results were similar to our study regarding IOP presentation and at follow-up.6 The 1991 Delhi study on PMG was not able to control IOP in 37.5% eyes.8 The 1990 Vellore study on PLG has found no significant correlation between duration of symptoms and the presenting IOP, as in the present study. There was a weak positive correlation found between the duration of symptoms and the best-controlled preoperative IOP, similar to the present study.9Lahan study has achieved slightly better IOP control than our study, especially after antiglaucoma medication.Optic disk at the last follow-up in the affected eyes was normal in majority (58%) of cases. Glaucomatous disk damage was found in 42% cases. Though clinically significant disk damage was found more in PMG (41.86%) than in PLG (42.85%), the difference was statistically not significant (p > 0.05). There was significant damage in cases presented beyond 2 weeks (64.28%) and especially beyond 30 days (100%) than in cases presented before 2 weeks (4%). Fundus was normal in majority (96%) of cases presented before 2 weeks. The severity of GDD was directly proportional to the duration of symptoms, which was clinically and statistically significant (p < 0.01).The BCVA at the last follow-up correlated with fundus changes and has shown that the good visual acuity achieved in normal fundus (68.97%) was significantly high than in cases with GDD (915.4%). In addition, poor visual acuity in cases with GDD was definitely high (61.90%) as none of the cases with normal fundus had poor visual acuity which were clinically and statistically significant (p = 0.0001).6 In Lahan study series, the percentage of optic atrophy cases (34.0%) is comparatively high from our study (15.56%).5In Madurai study, 5 patients with PMGs and 4 patients with PLGs had compromised optic nerves due to the glaucomatous process itself, showing close association with our study inference.The LIGs are a condition of old age with increased risk in females. The results have shown that good visual acuity can be achieved in LIG presenting within 2 weeks, with IOP of less than 35 mm Hg and with meticulous control of IOP and inflammation with medications preopera-tively. Planned manual small-incision cataract extraction with IOL implantation, minimal tissue handling, a good follow-up with efficient management of attendant complications, and inflammation are the key factors in the management.Delay in presentation of more than 2 weeks and IOP of more than 35 mm Hg would result in severe inflammation, affecting the optic nerve, which would ultimately imperil vision in these potentially blinding LIGs. Emphasis should be made on creating awareness about cataract, its implications among the rural community, ophthalmic assistants, and peripheral health workers. This study has highlighted the characteristics, risk factors, and their consequences in LIGs, and also the importance of early diagnosis and efficient medical management to control IOP and inflammation, with meticulous surgery and IOL implantation. Also proficient postoperative management and follow-up would probably achieve excellent visual prognosis.


Many scoring systems have been designed to predict mortality in surgical patients; however, these systems require the collection of several parameters that may not be available at ICU admission. As a result, these classification systems are not used as a routine part of clinical practice. The aim of this study was to evaluate the prognostic value of ASA classification predicting ICU and hospital mortality.P > 0.05. Areas under the ROC curve using ASA and ASA/ admission categories were constructed.We analyzed the records of 11,230 ICU admissions. ASA and elective/nonelective nature of the admission were combined into eight categories. We used the chi-square test and accepted the null hypothesis if P < 0.00001). The nonelective nature of the hospital admission was also associated with higher risk of death at the ICU (P < 0.0001) and in the hospital (P < 0.0001). Gender and hour of admission was not associated with the death rate. The combination of ASA classification with the nonelective nature of the hospital admission produced an eight- category index significantly associated with mortality (P< 0.00001). Analyzing hospital mortality, the area under the ROC curve was 0.77 (95% CI 0.74 to 0.79) for this index and was 0.72 (95% CI 0.69 to 0.75) for ASA. When analyzed for death at the ICU the AUROC was 0.71  for ASA and 0.75  for ASA nonelective admission index.We included 5,998 patients admitted to the ICU immediately after surgery. Forty-one percent were older than 65 years and 51% were female. Length of stay previous to ICU admission was 2.5 ± 6.1 days and duration of ICU stay was 1.9 ± 2.4 days. Elective hospital admission occurred in 65% of the patients. Neurosurgery with 21% of the procedures was followed by abdominal surgery (20%), and orthopedic surgery (15%). The death rate at the hospital was 6.9% (2.8% in ASA I patients and 31% in ASA IV/E). Higher ASA classification was significantly associated with the death rate both in the ICU and at the hospital (These results show that the ASA index can be used, preferably in combination with other data from electronic records, to predict mortality for surgical ICU patients.


The aim of the study is to evaluate the calibration and discrimination of two specific risk scores for community-acquired pneumonia (CAP) in patients with this illness who required ICU admission.t test to compare means and the chi-square test for univariate analysis. The standardized mortality ratio (SMR) and Hosmer-Lemershow test were calculated to analyze the calibration and ROC curve analysis for discrimination of different scores.A retrospective descriptive study of patients with severe CAP admitted to the ICU between January 2008 and September 2013. We analyzed clinical and epidemiological variables and APACHE II, SAPS III, CURB-65 and Pneumonia Severity Index (PSI) that were recorded in the first 24 hours. We used the Student P >0.05).We analyzed 111 patients aged 57.5 ± 17.7 years, with 63.1% (70) males. The APACHE II score at admission was 19.8 ± 17.7 and SAPS III was 60.6 ± 16.7. ICU mortality was 29.7% (33). There was association between the four scores and mortality. The SMR for APACHE II was 0.87 and 0.85 for the SAPS III. Figure The four analyzed scores presented good calibration, but discrimination seems better in SAPS III. Given the difficulty of calculating PSI, and its low discrimination (similar to CURB-65), we prefer to use the CURB-65 score in routine clinical practice.


Both parameters worsened with the severity of the initial sodium level. Hospital costs increased non-linearly with the severity of initial hyponatraemia. Hyponatraemia remained an independent predictor of 30 days in-hospital mortality, length of stay and costs in the multi-variable model.Healthcare systems in the developed world are struggling with the demand of emergency room presentations; the study of the factors driving such demand is of fundamental importance. From a database of all emergency medical admissions  to St James’ Hospital, Dublin, Ireland, over 12 years (2002 to 2013) we have explored the impact of hyponatraemia on outcomes  and costs). Identified variables, including Acute Illness Severity, Charlson Co-Morbidity and Chronic Disabling Disease that proved predictive univariately were entered into a multivariable logistic regression model to predict the bivariate of 30 days in-hospital survival. A zero truncated Poisson regression model assessed LOS and episode costs and the incidence rate ratios were calculated. Hyponatraemia was present in 22.7% of episodes and 20.3% of patients. The 30 days in-hospital mortality rate for hyponatraemic patients was higher (15.9%  Many factors influence mortality in medical patients admitted to hospital as emergencies including age, altered mental status and the presence of co-morbidities such as ischaemic heart disease, diabetes mellitus, and stroke . CliniciAn abnormality in serum sodium is indicative of a disruption in the body’s water balance. Such disruptions can lead to serious clinical manifestations including convulsions, coma and even death . AbnormaThere is still debate as to whether outcomes are causally related to the presence and extent of hyponatraemia, or merely a proxy for mortality due to the underlying condition . The objSt James’s Hospital (SJH) serves as a secondary care centre for emergency admissions for its local Dublin catchment area of 270,000 adults. All emergency medical admissions are referred to one of nine teams operating a 1:9 24 hours on-call roster. The “on-call” system is covered by a “physician of the day” with a post-call review round. Emergency medical patients are admitted from the Emergency Department to an AMAU opened in 2003, under the care of a physician certified in General Internal Medicine and a Subspecialty  scheme, the patient electronic record, the emergency room and laboratory systems. HIPE is a national database of coded discharge summaries from acute public hospitals in Ireland . IrelandData held on the database includes the unique hospital number, admitting consultant, date of birth, gender, area of residence, principal and up to nine additional secondary diagnoses, principal and up to nine additional secondary procedures, and admission and discharge dates. Additional information cross-linked and automatically uploaded to the database includes physiological, haematological and biochemical parameters. Data was related to all emergency general medical patients admitted to SJH in the twelve years between 2002 and 2013.Each emergency medical patient was referred to the team of the “on-call” Acute Medicine Consultant—on-take for a 24 hours period—most ~90% remained under the care of the admitting consultant for the duration of their admission. Approximately 9.9% of our patients stay >30 days with a median LOS of 54.8 days . Consequently the LOS data represents a highly skewed distribution. Although the clinical episode is complete for the majority by day 30, some patients remain for social reasons related to the lack of long-term care facilities. We have therefore chosen a truncated end-point (at the 30-day endpoint) for analysis, to avoid these additional confounders.We assessed the ability of known predictors—Acute Illness Severity ,31, CharThe Charlson Co-morbidity index provides an evaluation of Co-morbidity . Co-morbWe recently described a chronic disability score, derived from counts of discharge ICD9/ICD10 codes, that strongly correlated with mortality and length of stay .Triage categories, based on the Manchester Triage System  were CatWe have data that permitted the cost of each clinical episode for emergency patients admitted between 2008–2012 to be calculated. The Republic of Ireland has proposed to introduce a Money Follows the Patient system, where a case based funding model with Diagnosed Related Groups (DRG’s), compares hospital costs, quality and efficiency. The calculation of costs per case is adjusted by reference to the relative cost weight of each DRG. The hospital costing of the price of an episode of care encompasses all costs appropriately associated with the delivery of that care including pay costs, non-pay costs and costs of diagnostics, medical services, theatres, laboratories, wards and overhead allocations as appropriate.The hospital uses a number of standard accounting costing methodologies. The predominant approaches used in this exercise were Activity Based Costing and Absorption Costing ,37. BothDescriptive statistics were calculated for background demographic data, including means/standard deviations (SD), medians/interquartile ranges (IQR), or percentages. Comparisons between categorical variables and mortality were made using chi-squared tests. The 30-day in-hospital survival outcome bivariate variable was assessed by fitting a logistic regression model for variables that were univariately predictive. Combining the significant predictors gave an AUROC of 0.87  to predict an in-hospital death by day 30. We used margins to estimate and interpret adjusted predictions for sub-groups, while controlling for other variables, using computations of average marginal effects . MarginsFor the LOS count data, we employed a truncated Poisson regression model, including some categorical variables  in the model as a series of indicator variables. The dependent variable LOS is a positive integer; it cannot have zero value. The data are truncated because there are no observations on individuals who stayed for zero days; the predictor variables were therefore regressed against LOS using the zero-truncated Poisson model. We used robust standard errors for the parameter estimates, as recommended by Cameron and Trivedi . The PoiAs hospital costs typically have considerable heteroscedasticity, we examined the impact of the predictor variable (hyponatraemia grouping), using quantile regression; this method models the relationship between the hospital costs and the conditional quantiles  of a predictor variable. Thus, traditional least-squares regression, requiring both normality and equal variance, does not perform well for these types of data . Quantilp < 0.10). Statistical significance at p < 0.05 was assumed throughout. Stata v.13.1  statistical software was used for analysis.Adjusted odds ratios (OR) and 95% confidence intervals (CI) or incidence rate ratios (IRR) were calculated for those predictors that significantly entered the model  or High Dependency Unit (HDU), who had completed the clinical episode or who had suffered an in-hospital death, within 30 days of admission. The proportion of males and females was 48.9% and 51.1% respectively. The median (IQR) length of stay (LOS) was 5.1  days. The median (IQR) age was 62.2  years, with the upper 10% boundary at 84.5. The Charlson Comorbidity Score of 0, 1, or 2 was present by episode in 45.7%, 27.3% and 27.0% respectively. The major disease categories (MDC) by episode were respiratory (26.0%), cardiovascular (16.5%), neurological (16.2%), gastrointestinal (10.7%), hepatobilary (5.0%) and renal (4.4%).The frequency of occurrence of each of the Acute Illness Severity risk groups was 4.3%, 9.4%, 13.5%, 15.3%, 15.4% and 30.6% and their respective 30 days in-hospital mortality risk was 0.3%, 0.12%, 0.63%, 1.4%, 4.7% and 23.9%. Charlson Co-morbidity frequency of groups 0, 1 and 2 was 53.7%, 23.0% and 23.3% and 30 days in-hospital mortality rates were 2.9%, 8.8% and 22.0% respectively. Between 2002 and 2013 with 66,933 episodes in patients admitted as a medical emergency, who completed the hospital episode or suffered an in-hospital death by day 30, only 14.7% of such episodes had no disabling disease code. The episode frequency of 1, 2, 3, or 4+ disabling codes  was 28.0%, 27.7%, 18.4% and 11.2% respectively. Their respective 30 days in-hospital mortality rates were 1.2%, 4.0%, 7.7%, 13.3% and 25.4% respectively. The frequency of Manchester Triage Categories 1, 2 and 3+ at presentation was 2.1%, 39.8% and 58.2%, respectively, with respectively in hospital mortalities of 43.8%, 11.6% and 5.5%, respectively. vs. 60.5 years : p < 0.001), remained in hospital longer  vs. 4.7 days : p < 0.001) were more likely to be female (51.4% vs. 48.2%: p < 0.001) (p < 0.001) or by unique patients—last admission only if >1 admission (15.9% and 6.9% p < 0.001). Patients with hyponatraemia was much more likely to be >60 years, have more chronic disabling disease (three or more disabling conditions) and more acute illness severity  < 0.001) ; patient< 0.001) .Hyponatraemia and 30 days in-hospital Mortality . vs. 3.8%: p < 0.001) or by unique patient (15.9% vs. 6.9%: p < 0.001). The Odds Ratio for such a death increased with the level of hyponatraemia at admission (compared with an admission Na+ ≥ 135 mEq/L)—for ≥131 to <135 mEq/L—OR 1.99 , for ≥128 to <131 mEq/L—OR 3.00 , for ≥120 to <128 mEq/L—OR 3.72  and finally <119 mEq/L—OR 3.72 . The overall risk of a 30 days in-hospital death for hyponatraemia when fully adjusted for Acute Illness Severity, Age, Chronic Disabling Disease, Manchester Triage Admission Category and Charlson Co-Morbidity Score was 1.38 . The fully adjusted risk by hyponatraemia groups were for ≥131 to <135 mEq/L—OR 1.22 , for ≥128 to <131 mEq/L—OR 1.51 , for ≥120 to <128 mEq/L—OR 1.75  and finally <119 mEq/L—OR 2.07 .Between 2002 and 2013, the overall 30 days in-hospital mortality for hyponatraemia was significantly higher, whether calculated by episode  p < 0.001) or by unique patient  vs. 4.0  p < 0.001). The incidence rate ratios increased with the level of hyponatraemia at admission (compared with an admission Na+ ≥ 135 mEq/L) for ≥131 to <135 mEq/L—IRR 1.25 , for ≥128 to <131 mEq/L—IRR 1.36 , for ≥120 to <128 mEq/L—IRR 1.35  and for <119 mEq/L—IRR 1.54 .A truncated Poisson regression model also modelled the LOS in relation to the predictor variable—including the categorical variables  in the model as a series of indicator variables. As the dependent variable LOS is truncated (observations are only positive), the different distribution requires an approach such as using the zero-truncated Poisson model . The hosThe overall LOS with hyponatraemia, when fully adjusted for Acute Illness Severity, Age, Chronic Disabling Disease, Manchester Triage Admission Category and Charlson Co-Morbidity Score was 1.36 . The fully adjusted risk by hyponatraemia groups were for ≥131 to <135 mEq/L—IRR 1.05 , for ≥128 to <131 mEq/L—IRR 1.05 , for ≥120 to <128 mEq/L—IRR 1.03  and finally for <119 mEq/L—IRR 1.16 .Hyponatraemia and hospital Episode Cost , Table 3Hyponatraemia at time of hospital admission was a significant predictor of in-hospital costs. Quantile regression demonstrated  the non-The current study demonstrates that hyponatraemia is an independent predictor of mortality, hospital LOS, and costs in unselected general medical admissions. Our study adds to the previous literature by demonstrating in our cohort that the effect of hyponatraemia is not fully explained by illness severity or co-morbidity . FurtherThere are significant potential clinical implications to these findings. As a minimum, the data suggest that hyponatraemia should arouse concern in clinicians that affected patients are at risk for adverse outcomes. Patients at higher risk of adverse outcomes have the potential for a greater benefit from the dedication of a physician’s limited time resources than those at low risk of events. This further justifies the role of serum sodium as a component of risk prediction scores and tools. There may be benefits to the active modification of the hyponatraemic state in these patients; however this will require further study to determine. This is of particular interest as unlike outcome predictors such as co-morbidity and disabling disease score, hyponatraemia is amenable to both preventive and corrective interventions.The impact of serum sodium on outcomes has been evaluated in a number of previous studies. Serum sodium has been shown to be an important prognostic factor in a range of diagnostic groups including heart failure, pulmonary hypertension and subarachnoid haemorrhage ,24,25,26Our study has several strengths. The use of a large dataset has allowed us to demonstrate that hyponatraemia is not an epiphenomenon, low serum sodium actively impacts on mortality rather than being a reflection of other risk predictors. We have included all unselected medical admissions including those sickest of the sick who are admitted to ICU or HDU. Our study therefore reflects real world clinical practice enhancing its relevance to practicing clinicians. The demonstration of a dose-response curve further enhances confidence in the veracity of the results.Like any study ours also has limitations. We have demonstrated an association between hyponatraemia and outcomes. While we have controlled for a multitude of other risk predictors this does not neccessarily imply causation. Residual unmeasured confounders may be present which modify the effects demonstrated here. Our study was based on a retrospective cohort, we are dependant on the accurate coding and recording of data over the course of the study. In addition our study was based in a single centre, the results will require verification in other centres to establish external validity.We have demonstrated an independent relationship between hyponatraemia and the key outcome measures of 30 days in-hospital mortality, length of stay, and cost of hospital admission.


Sepsis is a time-dependent process that must be early detected and treated. Automatic alerts may play an important role in prompt detection.To describe the clinical and epidemiological characteristics of patients with severe sepsis and septic shock detected by a sepsis unit in ED of a tertiary hospital and to analyse the influence of the IMPLEMENTATION OF AUTOMATIC ELECTRONIC ALERT PROGRAM (AEAP) on process indicators, length of stay and outcome of patients with severe sepsis and septic shock detected by a sepsis unit.During an two years period, severe sepsis and septic shock patients detected in a teaching hospital were prospectively evaluated, Clinical and microbiological variables and process indicators such as delay of lactate extraction, inadequate empirical antibiotic treatment (IEAT) rates and antibiotic administration were recorded. Mortality rates, % of admissions at ICU and length of stay were also collected. Two different periods were analysed in order to analyse the possible differences in process indicators, mortality rates and length of stay. Period A: From 1-October-2102 to 15-June-2013 when a manual electronic check list to guide the detection of these patients was applied and Period B: From 16-June-2013 to 30-September 2014 when AEAP was implemented. A univariate analysis was performed to define the possible differences between to periods using SPSS package (15.0). Statistical significance was considered when p value < 0.05.1039 cases of severe sepsis and septic shock were detected (34.1% septic shock). Mean age was 72 ± 15 years, APACHE II and SOFA score were 17.7 ± 6.5 and 5 ± 3 respectively. The primary focus of infection was the respiratory (42.5%) followed by urinary (25.4%). Global mortality was 23.3%. Antibiotic administration was performed at 161.9 ± 179.1 min. in period A and 153.74 ± 156.49 min. at period B (p = 0.25). No differences in delay of lactate extraction were found . The number of activations was higher in period B (254 vs. 785 episodes) however the rate of admissions in ICU diminished in a significant way.  Statistically significant differences were also observed for the rate of appropriate empirical antibiotic therapy (40% vs. 13%. p = 0.01) between two periods. Although there were no significant differences in global mortality rate (23.2% vs. 23.3%) and length of stay  between two groups when patients with LTS were excluded the diminution of mortality rates became significant .These intermediate results showed an clearly benefit of AEAP in terms of detection, diminution of admissions in ICU and mortality rates in patients without LTS without any changes in process indicators. A significant reduction of inappropriate empirical antibiotic therapy may be the cause of these improved results.


Therefore, we performed this multi-center, phase II study in China to evaluate the activity, safety and pharmacokinetics of clofarabine monotherapy in pediatric patients with R/R ALL.Clofarabine is a second-generation purine nucleoside analog, which requires intracellular phosphorylation by deoxycytidine kinase to be metabolized to the triphosphate form necessary for cytotoxic effect.Eligible patients were pediatric patients (younger than 21 years old) with R/R ALL confirmed by histology. Relapsed ALL was defined as ALL that relapsed after at least two times of antileukemia therapy. Normal cardiac, hepatic and renal function and Eastern Cooperative Oncology Group performance status (0–2) were also needed. Patients with AEs who had not recovered from prior therapy within 3 months after allogeneic or autologous stem cell transplantation and with central nervous involvement or active infection were excluded. The detailed inclusion and exclusion criteria are listed in The primary end point was overall response rate (ORR), comprised of complete remission (CR) and CR with incomplete recovery of courts (CRi), according to the NCCN guidelines for ALL. This trial was reviewed by the institutional ethics committees and was conducted according to the Declaration of Helsinki. Written informed consent was obtained from each patient or their legal guardians. This study was registered as NCT02544789.2 over 2 h daily for five consecutive days. During the first two induction cycles, patients without objective response were taken off the study, and responsive patients continued to receive consolidation for a maximum 11 cycles if their non-hematological toxicity were below grade 3. A 25% dose reduction was required when grade 3 or higher non-hematological, non-infectious events occurred and recovered within 14 days. The response was determined using the NCCN guidelines for ALL. The methods for response assessment are detailed in the Clofarabine was administered intravenously at 52 mg/mCmax (peak plasma concentration), AUC (area under the plasma concentration−time curve), Tmax (time to achieve Cmax), serum clearance, half-life time and other parameters.Four patients signed written informed consent to blood draws for pharmacokinetic analysis . The datP<0.05 was considered statistically significant.Fisher's test was used for the comparison of response rate. Kaplan−Meier methodology was used to estimate time-to-event outcomes. All analyses were carried out with SAS statistical software , version 9.1.3, and Forty-four patients were enrolled between 30 June 2009 and 25 November 2011 from five centers in China. Forty-three patients were evaluable for efficacy. Two achieved CR, and 17 achieved CRi, resulting in an ORR of 44.2%  with a median duration of 14.6 weeks , thrombocytopenia (88.6%), anemia (86.4%), nausea (45.5%), vomiting (36.4%), increased alanine aminotransferase (34.1%) and febrile neutropenia (29.6%). Cmax and AUC0−∞ values on day 5 exceeded those on day 1 by 581–414 and 2691.18–2566.29, respectively. The steady state was reached after consecutive 5-day intravenous infusion. The plateau plasma concentration was 102.14±14.53 ng/ml.et al.7 observed one CR and nine CRps (CR with incomplete platelet recovery) in 12 ALL patients who received clofarabine monotherapy, while Jeha et al.4 reported a 19.7% CR+CRp and a 30% ORR in 61 pediatric ALL patients. An European study enrolled 53 pediatric patients with pretreated R/R ALL, in which 28% patients achieved CR or CRp.5 Our study had a numerically higher ORR  than that reported in previous studies. The results should be considered in the context that new evaluation criteria were introduced, which use CRi instead of CRp and partial response  in previous criteria. Moreover, this study was a single-arm design with limited sample size, which also contributed to the results. We also see clinical benefit of clofarabine in terms of duration of remission. The median duration of remission in this study was 14.6 weeks, which allowed patients with suitable donors to proceed to hematopoietic stem cell transplantation and prolonged the survival.This study indicated that single-agent clofarabine was active and well tolerated in heavily pretreated pediatric patients with R/R ALL in China. The ORR in this study was 44.2% , which was quite encouraging considering the heavily pretreated population enrolled. The activities of clofarabine compared favorably with prior studies evaluating single-agent clofarabine. Hagop 4 Myelosuppression-associated complications were ~88.6–93.2%, which were slightly higher than the data reported (31–81%) in prior study.10 These findings suggest that close monitoring is needed on liver function and blood count during clofarabine administration. The toxicity profile was consistent with the prior studies of clofarabine monotherapy, and no unexpected toxicities or treatment-related death was reported in the present study.A favorable toxicity profile was also seen. Most toxicity was tolerable and reversible. Grade 3 or 4 hepatic toxicities were recorded in 20.5% patients (9/44), compared with 15–46% in a previous study.2 and 170 L/m2, respectively, with an estimated terminal half-life of 6.2 h in Western children.11 In our study, the above-mentioned parameters were 20.42 L/h/m2, 186.66 L/m2 and 6.43 h, respectively. The heterogeneity of clofarabine among the individuals and limited sample size contributed to the results.Population pharmacokinetics study of clofarabine demonstrated that the systemic clearance and volume of distribution at steady state were 28.9 L/h/mIn summary, the results from this study revealed that clofarabine as a single agent is active and well tolerated in heavily pretreated Chinese pediatric patients with R/R ALL. Further studies are needed through other hematologic and solid tumors, adults and in combination strategies.


Objective of this study was to investigate the effect of different levels of iodine supplementation on iodine content of eggs in laying hens.1 was control basal layer diet without iodine enrichment in which iodine content (I2) was as per NRC recommendation. Basal diets were supplemented with calcium iodate (Ca (IO3)2) at 5, 10, 15 and 20 mg/kg in T2, T3, T4 and T5 groups, respectively. The iodine content in the calcium iodate is 65.21%, therefore, the diets T2, T3, T4 and T5 contained 3.25, 6.50, 9.75 and 13.0 ppm iodine, respectively. The laying hens were fed the respective experimental diets ad libitum during the experimental period of 10-week. The iodine content of egg yolk and albumen was analyzed at the end of 5th and 10th week of the experiment. Economics of feeding for the production of iodine enriched egg was calculated at the end of the experiment.In the experiment, 135 laying hens (White Leghorn) of 55 weeks age were randomly distributed to 5 dietary treatments; each group contained 27 laying hens distributed in three replicates of 9 birds each. Diet T3 diet (6.50 ppm I2). However, feeding cost of hens receiving 3.25 and 9.25 ppm I2 was statistically (p<0.05) similar to control group (T1). Further, it was noticed that feeding cost (Rs. per dozen or per kg eggs) was significantly increased due to the inclusion of higher level of iodine (13.0 ppm).Increasing iodine levels in diet of hens from 0.45 to 13.0 ppm significantly increased egg iodine concentration, the highest concentration of egg iodine was observed in the group fed diet supplemented with 13.0 ppm iodine followed by those fed 9.75, 6.50, 3.25 and 0.45 ppm iodine in diet. There was no significant difference in the iodine levels of unboiled versus boiled eggs. Therefore, the consumers are ensured to receive the optimal levels of iodine from boiled iodine-enriched eggs. Among different diets, minimum and significantly lower feeding cost (Rs. per dozen or per kg eggs) was noticed in hens allotted TIt was concluded that supplementing iodine at 6.50 ppm in layers diet was economically better for the production of iodine enriched eggs followed by feed iodine supplementation at 3.25 ppm as compared to control and other treatment groups. Egg is considered as a complete food with the most of the nutrients required for well-being. In addition to the nutrients already available in the egg if we can alter or incorporate certain health beneficiary nutrients then these eggs will be the choice of food for health conscious people and can reduce the chances of occurrence of certain diseases. Enriched egg with trace minerals results in eggs with superior biological and nutritional value for human consumption . Surveys2) is an essential micronutrient for humans and animals and its deficiency reduces the production of thyroid hormones, leads to the morphological and functional changes of the thyroid gland [Iodine , in which iodine (I2) content was as per NRC [3)2) at 5, 10, 15 and 20 mg/kg in T2, T3, T4 and T5 groups, respectively. Therefore, dietary iodine (I2) content in diets T2, T3, T4 and T5 was 3.25, 6.50, 9.75 and 13.00 ppm, respectively. All the diets were formulated as per NRC [In the experiment, 135 laying hens (White Leghorn) of 55 weeks age were randomly distributed to 5 dietary treatments; each group contained 27 laying hens distributed in three replicates of 9 birds each. T per NRC  recommenad-libitum to the hens in feeders. Care was taken that feeders are full of feed at all time and constant watch was kept to avoid feed wastage. An ample supply of clean and fresh drinking water was made available to the laying hens all the time through simple water channel type waterer. During the experiment, the eggs were collected thrice daily, i.e., at 9.00 am; 12.00 noon and at 3.00 pm replicate wise and where weighed at 4.00 pm daily.All the laying hens were shifted to experimental layer house. The system of rearing was cage system. The house was cleaned, white washed, fumigated, and sprayed with disinfectant before introducing the birds in it and was provided with a sufficient light source. Layer mash was offered th and 10th week of the experiment for iodine estimation. The iodine concentration in the egg yolk and albumin was determined by a spectrophotometer method (440 nm) using alkaline ashing based on the Sandell-Kolthoff reaction [4+ to Ce3+ in the presence of As3+ and the catalytic effect of iodine. Mineralization took place in an alkaline medium at 600°C. In this method, organic sample fades away as the result of a high temperature and iodine released from the organic compound attaches to alcoholic group. The resulting product was not soluble in acid and thus the iodine content was determined chromatographically. In this method, iodine catalyzes a reductive oxidation reaction. In the same manner the iodine content was also measured after boiling the eggs.Total 60 eggs (12 eggs from each treatment) were collected randomly at the end of 5reaction . The priAll the experimental diets were analyzed for proximate compositions as per AOAC . The ecoThe data obtained during the experiment were analyzed statistically using the methods described by Snedecor and Cochran . Differeth week of supplementation is presented in th week of supplementation indicated that the inclusion of different levels of iodine significantly (p<0.05) increased iodine content of egg yolk as well as albumen. Maximum and significantly (p<0.05) higher iodine content in egg yolk (1.17±0.025 µg/g) and egg albumin (0.12±0.001 µg/g) were recorded in layers assigned T5 (13 ppm I2) diet. Iodine content in egg yolk and albumen linearly decreased in layers assigned T4 (9.7 ppm I2), T3 (6.50 ppm I2), and T2 (3.25 ppm I2) diets, respectively. Minimum and significantly (p<0.05) lowest concentration of iodine content in egg yolk (0.19±0.005 µg/g) and egg albumin (0.02±0.002 µg/g) was found in layers assigned T1 (control) diet. The treatment means of the iodine concentration in eggs (after boiling) indicated that the use of higher levels of iodine significantly (p<0.05) increased iodine content of egg yolk as well as albumen. Maximum and significantly (p<0.05) higher iodine content of egg (after boiling) was noted in layers assigned T5 (13 ppm I2) diet. Iodine content in boiled egg yolk and albumen linearly decreased in layers assigned T4 (9.75 ppm I2), T3 (6.50 ppm I2) and T2 (3.25 ppm I2) diets, respectively. It was observed that about 10-15% iodine was lost after boiling the eggs.The concentration of iodine in egg yolk and albumen (before and after boiling) of laying hens fed on various levels of iodine after 5th week of supplementation (before and after boiling) is presented in the 5 (13 ppm I2) diet. Iodine content in egg yolk and albumen linearly decreased in layers assigned T4, T3 and T2  diets, respectively. Significantly (p<0.05) lowest iodine concentration in egg yolk and albumin was found in layers assigned T1 (control) diet. The treatment means of the iodine concentration indicated that, use of higher levels of iodine significantly (p<0.05) increased iodine content of egg yolk as well as albumen. Further, it was observed that about 10-15% iodine is lost on boiling the eggs.Iodine concentration in egg yolk and albumen (before and after boiling) of laying hens fed various levels of iodine after 102). Further, inclusion of higher levels of iodine significantly (p<0.05) increased the feeding cost (Rs. per dozen or per kg eggs) in layers. Feed cost (Rs. per kg) was near about similar in all treatments since the price of iodine source was very low.The economics of feeding for the production of iodine enriched eggs is presented in th week and 10th week of supplementation, linearly increased with the increasing iodine levels  in their diets. This increment may be due to the higher iodine transfer from feed to egg. The results of iodine concentration are consistent with the findings of Kaufmann et al. [et al. [et al. [et al. [et al. [et al. [et al. [et al. [Iodine content in eggs yolk and albumen, both after 5 [et al.  indicate [et al.  found th [et al. . Saki et [et al.  indicate [et al.  stated t [et al.  found th [et al.  in their [et al.  who recoet al. [et al. [In this study, the reduction in the iodine content of eggs after boiling ranged between 10% and 15%. In concurrent to this lower iodine recovery in the case of egg boiled for 30 min was also reported by Lipiec et al. . While,  [et al.  studied et al. [Among iodine supplemented diets, minimum and significantly (p<0.05) lowest feeding cost (Rs per dozen or per kg egg mass) was noticed in layers receiving 6.50 mg/kg iodine in their diet. Further, the inclusion of higher levels of iodine significantly (p<0.05) increased the feeding cost in layers. In support to our results, Malak et al.  also repFrom the results of the present experiment, it was concluded that iodine at 6.50 ppm in layers diet was economically better for the production of iodine enriched eggs followed by feed iodine supplementation at 3.25 ppm as compared to control and other treatment groups.SN and RPSB have designed the plan of work. SS carried out the laboratory work and analyzed the results. AN and CDM drafted and RK revised the manuscript. All the authors read and approved the final manuscript.


During 2010–2011, women were more likely than men to often feel depressed (10.7% compared with 7.7%), overall and among those aged 18–44, 45–64, and 65–74 years. For both men (9.9%) and women (13.0%), the prevalence of depression was highest among those aged 45–64 years.Source: National Health Interview Survey, 2010 Quality of Life and 2011 Functioning and Disability supplements. Data are from a subset of the adults randomly selected for the Sample Adult Component of the National Health Interview Survey questionnaire. Available at http://www.cdc.gov/nchs/nhis.htm.


Dental instrumentation has long provided insight into the mechanism of musculo-skeletal function of the gnathic system. While large population studies associate dental arch displacement (DAD), especially laterally, with symptoms, mandibular condyle displacement (CD) resulting from DAD has not been targeted as possibly etiologic in the production of common muscle contraction headache (CMCH) and temporo-mandibular dysfunction (TMD). The objective was to evaluate the three-dimensional nature of DAD and CD between the seated condylar position (SCP) and the intercuspal position (ICP) and to compare results derived from large deprogrammed asymptomatic and symptomatic populations. A total of 1 192 sets of dental casts collected from asymptomatic and symptomatic populations were articulated in the SCP. The initial occlusal contact, DAD, and condylar displacement were evaluated for frequency, direction, and magnitude of displacement between the SCP and ICP. The data revealed significant displacement between the SCP and ICP of the condyles (displaced most frequently inferior (down) and posterior ) and substantially increased frequency and magnitude of displacement of the dental arches  in symptomatic subjects. These discrepancies were statistically significant and clinically significant. The data support the concept of increased DAD and CD with dysfunction. Transverse condylar displacement, commonly presenting with dental cross bite, may be associated with CMCH and TMD. Displacement of the mandibular condyle may be an etiologic factor in CMCH and dysfunction of the temporo-mandibular joint. The difference is associated with contradictory theories of jaw movement, jaw recordings of positional and dynamic states, and the selection of dental instrumentation (articulators) for diagnosis and dental rehabilitation. It is, therefore, an important topic for further study and greater understanding.16 This is illustrated in Occlusal relationships and condylar position exist in three dimensions. Therefore, a definitive description of occlusion includes an assessment of not only the dental arch displacement (DAD) observed intraorally or from hand-articulated dental casts, but also dental casts articulated accurately in the SCP to assess mandibular condyle position resulting from intercuspation of the teeth.19 The magnitude (mm) and direction , vertical=superior-inferior (SI), and transverse=medial-lateral (ML)) of any discrepancy between the SCP and ICP is determined utilizing this instrumentation, which is illustrated in Condylar position instrumentation records positional changes of the mandibular condylar axis between the SCP and ICP in three spatial planes. Its accuracy, reproducibility, and reliability have been confirmed.n=596) deprogrammed symptomatic patient population and compare it to the same analysis performed on a large (n=596) deprogrammed asymptomatic population published previously.2The purpose is to statistically evaluate the three-dimensional , vertical (SI), and transverse  nature of DAD and condylar displacement (CD) between the SCP and ICP in a large Noise in the TM joint(s) , grating (crepitus))Locking of the TM joint(s)Pain upon movementParafunction Occlusal wear/attrition For the purpose of this study, the term “symptomatic” is defined as “with temporo-mandibular dysfunction,” meaning presence of the following signs or symptoms of TMD:The term “asymptomatic” is defined as “without temporo-mandibular dysfunction,” meaning absence of any of the above signs or symptoms of TMD.The samples matched closely with regard to age and gender. 325 female and 271 male asymptomatic subjects and 389 females and 207 male symptomatic subjects were evaluated. The mean age of the 596 asymptomatic subjects was 16 years 6 months, ranging from 9.4 to 58.3 years . The mean age of the 596 symptomatic subjects was 18 years 4 months, ranging from 8.1 to 66.5 years .2 They are summarized as follows.The techniques for neuromuscular deprogramming, ICP and SCP registration, dental cast articulation, three-dimensional model analysis, condylar position recording, error testing, and statistical analysis have been described previously.Pretesting records consisted of written patient medical and dental histories, a clinical examination, maxillary and mandibular dental casts, a bite registration in the ICP (to prevent rocking of the casts during recording of the mandibular condyle position), a bite registration in the SCP (after deprogramming of the neuromusculature), and the use of routine dental instrumentation  and mounting of upper and lower dental casts on the Panadent articulator in the SCP). The Panadent Condyle Position Indicator device was utilized to register the position of the mandibular condyles in three planes.All subjects were neuromuscularly deprogrammed (relaxed) at the chair prior to registration of the SCP by biting continually with a moderate pulsating biting force  on a wooden tongue depressor for 5 to 10 min.The two-piece wax bite registration of the SCP immediately followed neuromuscular deprogramming. This method avoids tooth contact and allows the subject's own mandibular elevator muscles to seat the condyles in a reproducible musculo-skeletal position without dental interferences. No attempt was made to manipulate the subject's mandible into position.Horizontal AP: overjet (OJ), occlusal (bite) classification at canine and first molar R+L;Vertical SI: overbite (OB);Transverse ML: dental midline.After mounting the dental casts on the articulator in the SCP, the three-dimensional dental cast analysis followed. The initial occlusal contact in the SCP was marked with colored articulating paper , and these parameters were measured to the nearest 0.2 mm with a Boley gauge in the SCP and the ICP:The three-dimensional mandibular condyle position registration and measurement conducted for each dental cast mounting is described in refs. All tests were run at the 95% confidence level. A statistical report was created from the dental arch and condyle position data and used in the analysis. Three-dimensional DAD and condylar displacement were measured and evaluated for frequency, direction, and magnitude of displacement between the SCP and ICP. Correlation between occlusal (bite) classification differences, the magnitude of mandibular condyle displacement (CD), and the relationship between condylar displacement and subject age and gender were determined.Intra-operator error for the reproducibility of the SCP registration technique, dental inter-arch measurements, and condylar position registrations were determined by having the same operator perform dental inter-arch measurements and condyle position registrations on the same instrument from two different sets of SCP registrations, taken of 20 subjects at two different sessions within a 3-week period. The new SCP registration was used to remount the initial lower dental cast. Dental inter-arch measurements and condylar position registrations were compared for the two articulator mountings.The 95% confidence level was used to test for statistical significance  The Wilcoxon signed-ranks test was used to determine statistical significance between measures in the ICP and the SCP. The Pre-Test/Reliability Study showed that there was no statistical difference between the two sets of dental inter-arch measurements or condyle position registrations. Using Reliability of Measures it was found that the SCP registration technique described was highly repeatable for all variables measured.In 560/596 asymptomatic subjects (94%), 562/596 symptomatic subjects , and 1 122/1 192=94.1% of the total sample  the initial occlusal contact occurred on the posterior-most tooth.Horizontal (AP) model analysis: OJ of upper and lower incisors. In 593/596 symptomatic subjects (99.5%) and 592/596 asymptomatic subjects (99.3%) the horizontal OJ of the incisors was larger in the SCP compared to the ICP. The symptomatic sample mean OJ was 4.91 mm  in the SCP and 2.45 mm  in the ICP (mean increase 100.4% (2.46 mm)). In the asymptomatic sample, mean OJ in the SCP was 5.19 mm  and 2.78 mm  in the ICP (mean increase 86.7% (2.41 mm)). Thus OJ doubled in the SCP in both samples.P<0.000 01).The difference between OJ in the SCP and the ICP was statistically significant in both samples (P<0.000 01).Angle classification has been used in dentistry to describe the type of skeletal and dental pattern, with Class 1 indicating a normal (straight) pattern, Class 2 indicating an OB pattern, and Class 3 indicating an underbite pattern. 40.9%  of asymptomatic subjects (244/596) displayed a change in pattern/classification at either the canine or the first molar between the SCP and ICP, which increased to 65.9%  of the symptomatic sample (393/596). This difference was statistically significant in both samples (P<0.000 01).596/596 (100%) symptomatic subjects' and 593/596 (99.5%) asymptomatic subjects' vertical OB of the incisors was smaller in the SCP compared to the ICP. The symptomatic mean OB in the SCP was 1.89 mm  and 4.35 mm  in the ICP (mean decrease 56.5% (2.46 mm)). The asymptomatic mean OB in the SCP was 2.06 mm  and 4.04 mm  in the ICP (mean decrease 49.0% (1.98 mm)). Thus, OB was reduced by half in the SCP. The difference between OB in the SCP and ICP was statistically significant in both samples (P=0.002 2). 62.2%  of symptomatic subjects' dental midlines were centered in the SCP as opposed to 53.2%  whose midlines were centered when the condyles were displaced into the ICP. This difference was statistically significant (P<0.000 01). 78.7%  of asymptomatic subjects and 58.2%  of symptomatic subjects' dental midlines were coincident in the SCP compared to the ICP. 21.3% (127/596) of asymptomatic subjects and 41.8% (249/596) of symptomatic subjects' dental midlines were different. The incidence of midline deviation between the SCP and the ICP doubled in symptomatic subjects.70.0%  of asymptomatic subjects' dental midlines were centered with condyles seated in the SCP, as opposed to 65.6%  with midlines centered when the condyles were displaced into the ICP. This difference was statistically significant  exhibited a vertical (inferior) displacement of both condyles from the SCP to the ICP. 1 167/1 192 asymptomatic condyles (97.9%) and 1 172/1 192 symptomatic condyles (98.3%) registered a vertical (inferior) condylar displacement  between the seated and intercuspal condylar position.n=1 192 subjects, n=2 384 condyles) was posterior-inferior (65.8%), anterior-inferior (28.5%), and straight inferior (4.2%). Therefore, the condyle was vertically (inferiorly) displaced from the SCP and most often positioned distally (posteriorly) when the teeth are occluded into intercuspation.66.7% (796/1 192) of condylar displacements in the asymptomatic sample and 64.9% (774/1 192) in the symptomatic sample were in a posterior-inferior direction; 25.4% (303/1 192) of asymptomatic and 31.5% (376/1 192) symptomatic condyles were anterior-inferior; and 5.7% (68/1 192) of asymptomatic and 2.7% (32/1 192) of symptomatic condyles were displaced straight inferior. The direction of condylar displacement from the SCP to the ICP in the total sample  and 532/596 symptomatic subjects (89.2%) had a vertical displacement greater than the horizontal displacement at both condyles. Only 69/596 asymptomatic subjects (11.5%) and 32/596 symptomatic subjects (5.3%) had horizontal displacements (anterior or posterior) with no vertical component.The mean horizontal R condylar displacement of the asymptomatic sample  increased to 0.99 mm  in the symptomatic sample. The mean horizontal L condylar displacement of the asymptomatic sample  increased to 1.04 mm  in the symptomatic sample.Mean vertical R condylar displacement of the asymptomatic sample  increased to 2.16 mm; SD=1.09; CI 2.07, 2.25; range 0-5.5 mm) in the symptomatic sample. Mean vertical L condylar displacement of the asymptomatic sample  increased to 2.23 mm; SD=1.13; CI 2.13, 2.32; range 0-5.4 mm) in the symptomatic sample. Mean magnitude of vertical displacement was more than two times greater than horizontal displacement in the majority of the 1 192 subjects.Mean transverse condylar displacement in the asymptomatic sample  increased to 0.82 mm; SD=0.39; CI 0.79, 0.85; range 0.1-2.7 mm) in the symptomatic sample.None of the 596 deprogrammed asymptomatic or symptomatic subjects exhibited a condylar position that was coincident in the ICP and SCP. All 2 384 condyles recorded displayed a displacement between the SCP and maximum intercuspation (MIC) in at least one plane.Displacements ⩾1.6 mm in the horizontal (AP) plane, ⩾2.0 mm in the vertical plane (SI), and ⩾0.5 mm in the transverse (ML) plane have been considered clinically significant. Using these parameters, 19.6% (117/596) of asymptomatic subjects had a displacement of ⩾1.6 mm horizontally , 53.0% (316/596) ⩾2.0 mm vertically , and 10.7% (64/596) ⩾0.5 mm transversely . This increased to 29.5% (176/596) of symptomatic subjects with a displacement of ⩾1.6 mm horizontally , 71.5% (426/596) ⩾2.0 mm vertically , and 87.6%  ⩾0.5 mm transversely.57.5% of asymptomatic subjects (343/596) exhibited a significant condylar displacement in at least one plane . This increased to 96.9% of symptomatic subjects (578/596).Horizontal and/or vertical displacement was ⩾2.0 mm in 53.6% of asymptomatic subjects (320 /596 patients) and increased to 73.3% of symptomatic subjects (437/596). 22.9% (137/596) of asymptomatic subjects had a horizontal or vertical condylar displacement of ⩾3 mm, which increased to 39.7% (237/596) of symptomatic subjects.P<0.000 01). 26.0% of asymptomatic subjects (155/596) displayed a significant vertical condylar displacement (⩾2.0 mm) and a discrepancy at the occlusal level as evidenced by a change in pattern/ classification at either the canine or the first molar between the SCP and ICP . This increased to 51.2% of symptomatic subjects .Correlation of vertical condylar displacement⩾2.0 mm with change in classification of skeletal and dental pattern at either the canine or first molar was statistically significant (P<0.00 01). 1.1% of asymptomatic subjects (7/596) displayed a significant horizontal condylar displacement (⩾1.6 mm) and a change in pattern/classification between the SCP and ICP . This increased to 4.2% (25/596) of symptomatic subjects .Correlation of horizontal condylar displacement⩾1.6 mm with a change in pattern/classification was statistically significant (P<0.000 01). 3.8% of asymptomatic subjects (23/596) displayed a significant transverse condylar displacement (⩾0.5 mm) and a change in pattern/classification between the SCP and ICP . This increased to 56.2% (335/596) of symptomatic subjects .Correlation of transverse condylar displacement ⩾0.5 mm with a change in pattern/classification was statistically significant (P<0.000 01). 26.6% (159/596) of asymptomatic subjects displayed a significant condylar displacement and change in pattern/classification between the SCP and ICP . This increased to 63.7% (380/596) of symptomatic subjects .Correlation of significant condylar displacement in any dimension with change in pattern/classification at either the canine or the first molar was statistically significant  mandibular position is often mistaken by the clinician for the SCP. Therefore, clinical mandibular manipulation is unreliable in determining the SCP because of the effects of the neuromusculature. The following prerequisites must be accomplished to achieve more complete condylar seating than has been achieved in previous condylar position research: neuromuscular deprogramming with a hard anterior stop, followed by a two-piece registration that incorporates a hard anterior stop, and finally, voluntary muscle contraction.To date, few studies of dental inter-arch and condylar position spatial relations have incorporated neuromuscular deprogramming before registering the SCP. This is an important distinction, because neuromuscular deprogramming before registering the SCP gives the clinician a more accurate representation of the three-dimensional dental inter-arch and condyle position spatial relationships as a result of more complete condylar seating. Neuromuscular deprogramming is the key to reproducibility.Initial occlusal contact on the posterior-most tooth.Horizontal (AP): more retrusive posteriorly, possible change in occlusion pattern/classification at the canine or first molar. Increased incisor OJ anteriorly.Vertical (SI): more open .Transverse (ML): dental midlines coincident .The results demonstrate that the majority of dental casts taken from neuromuscularly deprogrammed subjects and accurately mounted in the SCP  will show the following dental inter-arch characteristics when compared with the dental inter-arch relationship seen intraorally or from dental casts hand-articulated in the ICP:24 This finding is supported herein. Traditional dental casts collected for diagnosis and treatment planning that are hand-articulated into intercuspation do not reflect this scientific fact. The majority of human subjects have an initial occlusal contact on the posterior-most tooth in the SCP.23 The position of the condyles in the ICP has been proven to be different from the SCP in almost all individuals29 and this is supported herein. No correlation was found between age or gender and magnitude of condylar displacement in this or previous studies.16 These parameters are not accurate predictors of mandibular CD.Previous investigations have shown that occlusal characteristics are poor indicators of condylar position.9 Shildkraut et al.,11 Utt et al.,12 Crawford,14 Girardot,15 Hidaka et al.,16 Wood and Elliott,18 Karl and Foley,19 Roth,30 and Dawson,31 and supports the concept of vertical condylar displacement resulting from posterior initial occlusal contact.The direction of condylar displacement from the SCP to the ICP in the total sample was posterior-inferior (65.8%), anterior-inferior (28.5%), and straight inferior (4.2%). These percentages are in close agreement with Wood and Korne,The following clinical findings support the concept of increased mandibular CD in subjects with symptomatology (CMCH and TM dysfunction).23 These displacements increased in the symptomatic sample. For the sake of brevity, the detailed comparison of measurements of condylar position in three planes with other data presented in the literature is shown in Mean horizontal (AP) and vertical (SI) condylar displacements were higher than reported previously for an asymptomatic population.19 Nearly all symptomatic subjects (96.9%=578/596) exhibited a significant  condylar displacement in at least one plane.Displacements ⩾1.6 mm in the horizontal (AP) plane, ⩾2.0 mm in the vertical plane (SI), and ⩾0.5 mm in the transverse (ML) plane have been considered clinically significant.et al.,16 16% Utt et al.,12 19%). 22.9% of asymptomatic subjects had condylar displacements of ⩾3 mm horizontally (AP) or vertically (SI) and this is in agreement with Shildkraut et al.11 who found 25% (33/131) to have a discrepancy of ⩾3 mm. This nearly doubled to 39.7% of symptomatic subjects.The magnitude of horizontal (AP) or vertical (SI) displacement was ⩾2 mm in 53.6% of asymptomatic subjects and increased to 73.3% of symptomatic subjects. This incidence is larger than reported previously  condylar displacement of ⩾0.5 mm is the most clinically critical type of displacement and is significant in the production of signs and symptoms of CMCH and TM dysfunction. Mean magnitude of transverse (ML) condylar displacement of asymptomatic subjects (0.26 mm) increased to 0.82 mm in symptomatic subjects. 10.7% of asymptomatic subjects had a transverse (ML) discrepancy of ⩾0.5 mm—this increased to 87.6% of symptomatic subjects. This is a clinically significant finding and supports the hypothesis that transverse (ML) condylar displacement ⩾0.5 mm, commonly presenting with dental cross bite,P=0.015), who also exhibited increased frequency of bilateral condylar displacement inferiorly and distally (P=0.012).34These findings have been corroborated by three recent independent internationally published reports utilizing similar methodology. Weffort and Fantini found symptomatic subjects had increased mandibular CD in the horizontal, vertical, and transverse planes. Transverse displacement of asymptomatic subjects nearly doubled in symptomatic subjects  was found in 72.9% of experimental (symptomatic) and 11.4% of control (asymptomatic) groups (P<0.001). The SCP-ICP discrepancy was significantly correlated with signs and symptoms of TM dysfunction (P<0.01) and the degree of discrepancy positively correlated with severity of signs and symptoms. They concluded that the SCP-ICP discrepancy may be contributory to the development of TMD and is a reliable indicator of the presence and severity of TMD.35He et al. found significant deviations at the occlusal level in both groups between the SCP and ICP. Average vertical and horizontal condylar displacements were significantly greater in the symptomatic group and mean transverse condylar displacement of the asymptomatic group (0.61 mm) increased to 0.96 mm in the symptomatic group. They concluded that mandibular CD may play a significant role in the etiopathogenesis of TM disorders.36Padala 27It is not possible to detect a transverse (ML) condylar displacement of this magnitude except through use of dental condylar position instrumentation. Studies have measured the frequency and magnitude of transverse (ML) condylar displacement, but have not related this measurement to dysfunction. Furthermore, no relationship has been found between transverse (ML) condylar displacement and either horizontal (AP) or vertical (SI) displacements.26.6% of asymptomatic subjects displayed a significant condylar displacement  and change in occlusion pattern/classification at the canine or first molar between the SCP and the ICP. This increased to 63.7% of symptomatic subjects, indicating increased frequency and magnitude of both CD and DAD in symptomatic subjects.This prospective study compared the records from large asymptomatic and symptomatic populations. The results clearly demonstrate a strong, statistically significant difference and clinically significant difference in the occlusion  and condylar position in three dimensions between asymptomatic and symptomatic subjects. This difference was quantifiable at the level of the occlusion and at the level of the mandibular condyles. The data indicate increased frequency and magnitude of both DAD and mandibular CD in symptomatic subjects. CD, especially in the transverse plane, commonly presenting with dental cross bite, may be associated with signs and symptoms of TM dysfunction, including CMCH.In summary, this study represents a noticeable improvement with respect to the literature as it attempted to assess on a systematic basis (data were collected over 15 years on a large population of subjects) the relationship between mandibular condyle kinematics and TMD, including CMCH. However, finite-element simulations may prove useful in identifying potentially critical regions hosting high concentrations of stress and strain, which might lead CMCH and/or TM dysfunction. A comparison of mandibular condyle kinematics and finite-element analysis with regard to TM dysfunction is recommended in future investigations.An important implication of the present study is that the use of common dental instrumentation provides the clearest measurement of condylar position available. This is of crucial importance from a clinical perspective in that a prudent goal of dental correction would be to minimize condylar displacement whenever possible.


Serratia spp. are gammaproteobacteria and members of the family Enterobacteriaceae. Here, we announce the genome sequence of Serratia plymuthica strain V4, which produces the siderophore serratiochelin and antimicrobial compounds. Serratia is the pathogenic Serratia marcescens, a producer of a red prodigiosin pigment  was isolated from a biofilm that formed on the pasteurizer plate in a sanitized milk-processing line (ing line . This sting line  as well n V4 ZK49 was isoling line .Serratia sp. V4 was obtained from an overnight culture in LB medium (Merck) using the total DNA extraction DNeasy blood and tissue kit (Qiagen). The genome sequence was obtained by de novo sequencing using 454 technology , which resulted in 65 contigs with an average length of 85 kb . The relative order and orientation of the contigs were determined by comparison with whole-genome sequences available from other members of the genus, those of Serratia sp. strain AS12 (GenBank accession no. CP002774.1), S. plymuthica 4x13 , and Serratia proteamaculans 568 (GenBank accession no. CP000826.1), using the whole-genome alignment tool Mauve version 2.3.1  (Serratia sp. strain V4 displays a high degree of similarity (98% nucleotide identity) with the genome of S. plymuthica 4Rx13, though S. plymuthica 4Rx13 lacks key gene clusters involved in the biosynthesis of nonribosomal peptides and polyketides. For example, it lacks genes involved in the synthesis of zeamine (The genome of  to 60%) . The gen zeamine , as confS. plymuthica 4Rx13 is indeed the closest relative of Serratia sp. V4  confirmed that a sp. V4 . FormulaS. plymuthica V4 has been deposited in GenBank under the accession no. CP007439.The genomic sequence of


Cardiovascular complication should be evaluated in patient with T1DM. Ventricular instability  in Type 1 Diabetes Melitus (T1DM) is a risk factor for mortality. Prolongation of corrected QT interval (QTc) is accurate and the most sensitive test for the autonomic neuropathy whether QT interval dispersion (QTd) in arrhythmia is a predictor for mortality. This study is to evaluate arrhythmia, prolongation of QTc and QTd in T1DM children. Cross sectional study of children diagnosed T1DM in Soetomo Hospital; Surabaya during April 2013 to April 2014 was performed. The ECG was done in all of the patients. Arrhythmia, QTc and QTd were measured and analyzed with Paired t-test. There were 17 patients joint this study. Age was 8 to 15 years. There were 9 girls and 8 boys who suffered from 1 to 7 years of illness. There were 9/17 arrhythmia patients, 2/17 prolonged QTc patients, 4/17 borderline QTc patients, 1/17 with total AV block. The patient with total AV block was diagnosed DMT1 with ketoasidosis and acute pancreatitis. There was 1 patient without prolonged QTc although suffered from five times of DKA. The mean of QTc was 428.5 (SD 27.67) m.sec and QTd was 29.3 (SD 12.79) m.sec. There was significant differences between present of arrhythmia and QTd  and QTc . Arrhythmia and prolonged QTc was present in T1DM children under 10 years of illness. No one with prolonged QTd. Every arrhythmia should be taken into account in QTd to predict the mortality.


Chlamydia infections are notified at much higher rates in Aboriginal and/or Torres Strait Islander people compared to non-Indigenous people. The Australian Collaboration Chlamydia Enhanced Sentinel Surveillance System (ACCESS) was established to complement population-based surveillance.We describe patient demographics, completeness of recording of Aboriginal and/or Torres Strait Islander  status, chlamydia testing rates and positivity rates from the Aboriginal Community Controlled Health Service (ACCHSs), General Practice (GP) clinics and Sexual Health Services (SHSs) networks in ACCESS during 2009. Data were extracted from electronic medical records of each participating health service for consultations with patients aged 16–29 years and for chlamydia testing and positivity.Data were included from 16–29 year olds attending six ACCHSs ; 22 SHSs  and 25 GP clinics . Aboriginal status was unknown for 79.3% of patients attending GP clinics, 4.5% attending SHSs and 3.8% of patients attending ACCHSs. Chlamydia testing rates among Aboriginal patients were 19.8% (95%CI:18.6%-21.0%) at ACCHSs, 75.5% (95% CI:72.5%-78.4%) at SHSs and 4.3% (95% CI: 2.6%-6.6%) at GP clinics. Positivity rates were highest in Aboriginal patients tested at SHSs at 22.7% (95% CI:19.5%-26.2%), followed by 15.8% (95% CI:3.8%-43.4%) at GP clinics and 8.6% at ACCHSs (95% CI:7.9%-12.4%). This compared with non-Indigenous patients positivity rates at SHSs of 12.7% (95% CI:12.2-13.2%); 8.6% (7.2%-11.3%) at GP clinics and 11.3% at ACCHSs (95% CI:15.4%-24.9%).Higher chlamydia positivity in Aboriginal people across a range of clinical services is reflected in national notification data. Targeted efforts are required to improve testing rates in primary care services; to improve identification of Aboriginal patients in mainstream services such as GP clinics; and to better engage with young Aboriginal Australians. Chlamydia trachomatis is a sexually transmitted infection that is easily diagnosed and treated, but most infections go undetected since up to 80% are asymptomatic ; Western Australian (WA) Aboriginal Health Information and Ethics Committee; and the Human Research Ethics Committee of the NT Department of Health and Families and Menzies School of Health Research (NT). Approval for the GP network was granted by the Royal Australian College of General Practitioners (RACGP). Approval for the SHS network was granted by the Human Research Ethics Committees (HRECs) of St Vincent’s Hospital and the University of New South Wales with further ethical approval granted by the separate HRECs overlooking each of the 22 participating SHSs.Of the six ACCHS one was located in a metropolitan area and the remaining were in regional/remote areas, whereas the majority of the GP clinics  and SHSs  were located in metropolitan areas.Within ACCHSs 4,950 unique patients aged 16–29 years attended during 2009. Of these, 60% were female, 33% were aged 16–19 years and 37% were aged 20–24 years. In the 25 GP clinics, 34,462 unique patients aged 16–29 years attended during 2009; 61% were female, 26% were aged 16–19 years and 38% aged 20–24 years. In the same year, 20,691 16–29 year olds attended the 22 SHSs, of these 48.9% were female; 17% were aged 16–19 years and 44% were aged 20–24 years (Table The majority of patients (85%) attending ACCHSs were identified as Aboriginal, 11% as non-Indigenous, and in 4% this status was not recorded. Of all patients attending GP clinics, 1.3% were recorded as being Aboriginal, 31.2% as non-Indigenous, and for 67.5% of patients Aboriginal status was not recorded. Aboriginal patients comprised, 4.1% of the total patients seen at SHSs, with 91.5% recorded as non-Indigenous and for 4.3% Aboriginal status was not recorded  attending ACCHSs; 4.3% (95% CI:2.6-6.6%) at GP clinics, and 75.5% (95% CI:72.5%-78.4%) at SHSs (p < 0.01)  (72 of 833 patients tested), 15.8% (95% CI:3.4%-39.6%) (3/19) at GP clinics, and 22.7% (95% CI:19.5%-26.2%) (145/638) at SHSs (p < 0.01). Among non-Indigenous people, chlamydia positivity at ACCHS was 11.3% (95% CI:4.7%-22.0%) (7/62), 8.2% (95% CI:6.4%-10.1%) (75/920) at GP clinics, and 12.7% (95% CI:12.2%-13.2%) (1887/14851) at SHSs (p < 0.01) , while those tested at ACCHSs had a positivity rate of 9.4% . Among Aboriginal males chlamydia positivity rates within SHSs was 24.5% (95% CI:19.5%-30.0%) and within ACCHSs 8.1%   and one specialised (SHSs). The study is the first comprehensive analyses, and certainly the biggest that compares Aboriginal/non-Aboriginal populations using the same recruitment methods for both populations. Previous comparisons have been based virtually entirely on notification data, which is subject to variabililty due to dependence on testing uptake.Data from three different types of primary care services are represented, covering a period of 12 months with over 60,100 patients. Elsewhere, we reported the representativeness of participating sites according to Australian population distributions . AccordiAt the participating services, 4.1% of clients at SHSs were identified as Aboriginal, compared to 1.3% at GP clinics and 85% at ACCHSs. Aboriginal attendances in GPs and ACCHSs from this dataset were consistent with those reported in national audits across all ages, and affirm that young Aboriginal people only make up a small proportion of those attending mainstream encounters the patient identified as sexual health services for STI care and management. Of all patients attending GP clinics in 2011–2012 1.5% were identified as Aboriginal  while 78The Aboriginal status of patients was better recorded at ACCHSs and SHSs compared with GP clinics where only one third of patients status was recorded. Improving data quality on Aboriginal status within GP clinics is a priority of Australian Governments  with theThis study confirms that the majority of ACCHSs patients are Aboriginal people and that people aged 16–29 years attend these services for health care, including for STI screening. This concurs with two previous studies, the first, a cross sectional survey of young people aged 16–29 years where 54% reported that they had an STI test in the previous year and did so at an ACCHS , and a sClosing the Gap funding initiatives particularly involving ACCHSs [Further efforts are required to improve STI testing rates in primary care. Testing rates among Aboriginal patients attending ACCHSs and GP clinics were quite different with testing rates within ACCHS almost five times greater than that offered by GPs for both Aboriginal and non-Indigenous patients. As expected, testing rates were high among both Aboriginal and non-Indigenous patients attending SHSs. There are two main reasons to test for Chlamydia- to screen those who are asymptomatic or to diagnose symptomatic infection. Thus, chlamydia testing rates of services may reflect their adherence to screening protocols, as well as the burden of disease affecting their populations. With regards to screening, clinical practice guidelines recommend that all sexually active people up to the age of 29 years be offered a chlamydia test at least annually ,23. The g ACCHSs  but do nMathematical modelling has suggested that increasing rates of chlamydia testing to 40% in males and females aged less than 25 years or to 20% in young people aged less than 30 years could halve the prevalence of chlamydia within ten years; with most of this decline occurring within the first four years . If the A key strength of this study is that the results reflect actual clinical practice in the participating health services. All data were collected retrospectively and thus did not influence the decision to offer a chlamydia test or not. In addition, within each network, study data were collected from services that are geographically dispersed across the country; thus reducing biases introduced when data are reported from one service or region.A limitation of the study was the poor identification of Aboriginal patients at mainstream GP clinics with more than two thirds of patients having an unknown Aboriginal status. The poor completeness of Aboriginal status in GP clinics means we cannot be confident about the true testing and positivity rates in Aboriginal patients. In addition, the study did not record patients who declined to have a test when offered one. Clinical audits would be needed to measure the extent of decline in any of these primary care facilities. Further, we were not able to identify symptomatic patients from asymptomatic patients making interpretation of positivity results difficult to correlate with community prevalence rates. Only first patient visits involving Chlamydia testing were counted, thus excluding subsequent testing and positivity data. Finally, in view of the small sample size of GP clinics and ACCHSs in the ACCESS network, these findings may not be representative of all such health services because of the small sample size of these clinics in Australia.Closing the Gap initiatives that are directed at mainstream general practice [In conclusion, this study provides a snapshot of chlamydia testing and positivity among young people attending three types of primary care health services. Improved completeness of recording of Aboriginal status should be a priority in GP clinics, not only to evaluate chlamydia testing and prevention programs but also for other practice . QualityThe authors declare that they have no competing interests.JW conceptualized the study. JW, JG, HA and AB conducted the analysis. JW drafted the manuscript with assistance from JG, HA, RJG, SC and BD. JW, JMK, MH, RJG and BD are investigators on ACCESS. All authors contributed to the manuscript and read and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/14/285/prepub