Artemisia from 20.3 to 17.4 ka BP, subalpine meadow dominated by Cyperaceae and Artemisia between 17.4 and 14.4 ka BP, and forest steppe dominated by Betula and Artemisia after 14.4 ka BP. The pollen-based temperature index demonstrates a gradual warming trend started at around 20.3 ka BP with interruptions of several brief events. Two cold conditions occurred around at 17.2–16.6 ka BP and 12.8–11.8 ka BP, temporally correlating to the Henrich 1 and the Younger Dryas events respectively, 1and abrupt warming events occurred around at 14.4 ka BP and 11.8 ka BP, probably relevant to the beginning of the Bølling-Allerød stages and the Holocene. The pollen-based moisture proxy shows distinct drought condition during the last glacial maximum (20.3–18.0 ka BP) and the Younger Dryas. The climate history based on pollen record of Lake Moon suggests that the regional temperature variability was coherent with the classical climate in the North Atlantic, implying the dominance of the high latitude processes on the EASM evolution from the Last Glacial Maximum (LGM) to early Holocene. The local humidity variability was influenced by the EASM limitedly before the Bølling-Allerød warming, which is mainly controlled by the summer rainfall due to the EASM front covering the Northeast China after that.The Great Khingan Mountain range, Northeast China, is located on the northern limit of modern East Asian Summer Monsoon (EASM) and thus highly sensitive to the extension of the EASM from glacial to interglacial modes. Here, we present a high-resolution pollen record covering the last glacial maximum and the early Holocene from a closed crater Lake Moon to reconstruct vegetation history during the glacial-interglacial transition and thus register the evolution of the EASM during the last deglaciation. The vegetation history has gone through distinct changes from subalpine meadow in the last glacial maximum to dry steppe dominated by  GreenlaHolocene –11. TheyHolocene . In addiHolocene . MagnetiHolocene . The infHolocene –19.The Great Khingan Mountain range is located in the northern boundary of the EASM. In biogeography, this area is a boreal-temperate forest transition zone in north-south direction as a reaction of temperature gradient, and a woodland-to-grassland transition zone in east-west direction as a response to monsoonal rainfall extension. The vegetation evolution in the region might be sensitive to the rapid climate changes. It is expected that the vegetation history recorded in this region could capture the regional monsoon variations in response to large climatic changes during the last deglaciation. Here, we report a high-resolution pollen record from Lake Moon with aims to understand how the regional monsoonal climate responded to the shift in glacial/interglacial modes.Larix gmelinii with other important species include Picea koraiensis, Betula platyphylla, Quercus mongolica, Betula davurica, Populus. The temperate deciduous broadleaved forest in the southeastern slope is characterized by Quercus, Acer, Betula and Tilia. The forest-steppe is distributed in the western slope of the Great Khingan Mountain. The steppe communities are dominated by Stipa baicalensi, Aneurolepidium chinense, Filifolium sibiricum, Carex spp., while the isolated forest patches are formed by the major species of B. platyphylla, B. dahurica, Q. mongolicus and L. gmelinii. The steppe vegetation increased in the west and composed mainly of Stipa grandis, Stipa krylovii, Cleistogenes squarrosa, and Artemisia frigid with minor components of Agropyrum cristatum, Aneurolepidium chinense, Carex duriuscula, Artemisia spp. and Achnatherum splendens [The Great Khingan Mountain range forms a natural border between Inner Mongolia Plateau and Songliao Plain, which is constituted by a series of shallow hills arranged from northeast to southwest in the northeast China. The modern vegetation in the Great Khingan Mountain range varies from cold temperate conifer forest (Euro-Siberian taiga forest) in the north, to the temperate deciduous broadleaved forest in the southeastern slope. According to the precipitation or humidity gradient along east-west transect, the Great Khingan Mountain is a transitional zone from temperate deciduous broadleaved forest to forest-steppe. The dominant species is plendens .We selected a small closed crater lake, Lake Moon , as study site. This lake is located in the middle of the Great Khingan Mountain range , in ChaiPresent climatic conditions show a pronounced seasonality with a warm and humid summer and a cold and dry winter. The mean annual temperature during AD 1982–2011 is -2.3°C and the mean annual precipitation is 442 mm, in which 63% precipitation occur in summer season (June to August) . Lake MoL. gmelinii, B. platyphyll and B. dahurica, with a shrub layer of Corylus heterophylla, Rhododendron dauricumand, Lespedeza bicolour and Pyrola calliantha, and the herbaceous species including Iris uniflora, Deyeuxia langsdorffii, Artemisia integrifolia, Artemisia gmelinii, Artemisia tanacetifolia, Fragaria orientalis, Sanguisorba officinalis, Vicia unijuga and Saussurea ciliaris. Salix spp. and Spiraea salicifolia shrubs are distributed sporadically about 25m away from the lakeshore. The hygrocolous communities around the lake are dominated by Deyeuxia angustifolia, Deyeuxia langsdorffii, Carex appendiculata and Carex rhynchophysa.The modern vegetation in the catchment of Lake Moon is composed of a deciduous broadleaf-conifer mixed forest. The forest is dominated by All necessary permits were obtained for the described field work and were granted by the local government of Inner Mongolia. The field work did not involve endangered or protected species.14C dates were obtained from Poznan radiocarbon Laboratory, of which 15 samples above 610 cm are plant macro remains ; and 6 samples below 610 cm are bulk sediment, all age data have been published before [Three over-lapping piston cores were recovered from the center of Lake Moon in the early spring of 2007. The sediment is presented as dark brown finely laminated gyttja from 0 to 590 cm; brown organic-rich laminated clay from 590 to 732 cm; and grey clay from 732 to 886 cm. Twenty-one AMS d before .Lycopodium spores were added in order to calculate the pollen concentration (grains g-1). One hundred and seventy-one subsamples were prepared with alkaline and acidic treatments [The cores were split in half longitudinally and subsamples for pollen analysis were taken at intervals of 2 cm from 546 cm to the bottom of the core. eatments , followeeatments ,25. More14C ages have been calibrated to calendar age by CALIB6.01  program using IntCal09 database [14C ages through depth suggests that the old carbon effect in this lake could be neglectable.All the database ,27 , Poaceae (19.1–37.1%), Cyperaceae (14.6–20.7%), and abundant Chenopodiaceae and Thalictrum with low pollen concentration (5.2×103−21.7×103 grains g-1). The coniferous (0.2–1.0%) and deciduous broad-leaved (0–8.5%) taxa are sparse. In contrast, the percentage of aquatic taxa is relatively high contributed from Myriophyllum (0.8–4.8%).Zone 1 : This zone is characterized by the dominant herbs (86.8–99.5%), Artemisia (22.5–67.4%), Poaceae (8.9–34.7%), Chenopodiaceae (2.7–12.9%), and also some meadow taxa like Cyperaceae (0–34.5%) and Thalictrum (2.3–7.4%). There is a peak of Cyperaceae with a sharp decrease of Artemisia between 19.0–18.8 cal. ka BP It still has low percentage of coniferous (0–2.3%) and deciduous broad-leaved (0–3.9%) pollen and low pollen concentration (2.4×103−22.7×103 grains g-1).Zone 2 : This zone is also dominated by herb components (94.4–99.2%), mainly of dry steppe taxa, Betula (0–16.8%), at the expense of steppe taxa like Artemisia (13.7–55.1%). Pollen component still dominated by a variety of herbs including Poaceae (11.5–24.0%), Chenopodiaceae (1.8–11.4%), and Thalictrum (1.2–5.6%) besides the two taxa mentioned above. The pollen concentration (10.9×103−98.8×103 grains g-1) increases slightly with the first sign of the increasing percentage of trees.Zone 3 : This zone is marked by high alpine meadow taxa mainly of Cyperaceae (2.9–51.2%) and increasing of Betula (5.0–52.0%). Reduced herbs components include Artemisia (26.1–67.6%), Poaceae (1.2–15.2%) and Chenopodiaceae (0.5–7.6%). Pollen concentration is 3.9×103−97.0×103 grains g-1 in this zone.Zone 4 : It features relative high and various deciduous broad-leaved components as Betula and Artemisia. 4a is characterized by the increase of Betula (5.0–52.0%); 4b is marked by decrease of Betula (16.4–33.7%) and increase of Artemisia (50.4–63.7%); 4c has relative high percentage of Betula (26.1–44.9%) and low percentage of Artemisia (26.9–47.4%).Zone 4 can be divided into 3 subzone based on the percentage of trees and herbs pollen, mainly of Betula (17.7–42.7%) accompanied with relative high herbs component includes Artemisia (31.4–61.7%), Poaceae (5.2–17.0%) and Chenopodiaceae (1.2–6.0%) compared to last zone. The low pollen concentration (4.3×103−97.0×103 grains g-1) associated with rise of herbs indicates the steppe component expands.Zone 5 : This zone features relative low deciduous broad-leaved component (17.7–42.7%) mainly 3−0.4×106 grains g-1). This zone was dominated by herbs (37.3–75.6%) and deciduous broad-leaved (23.4–61.4%) component including steppe taxa like Artemisia (29.1–61.8%), Chenopodiaceae (1.9–8.1%) and broad-leaved forest taxa as Betula (23.2–61.2%).Zone 6 : It is characterized by the high pollen concentration  to brown clay and black organic-rich clay with discontinued lamina, indicates that the lake water level increased probably due to increasing moisture or precipitation and suggests that the EASM became stronger. However, some cold climate events have possibly occurred, such as 13.6, 13.4–13.2 (Subzone 4b), 13.0 and 12.8–11.8 ka BP (Zone 5), implied by high proportion of herbs and lower proportion of trees suggesting the weakening of the EASM.A substantial change of the vegetation took place between ~ca. 14.4 and 13.4 ka BP (Subzone 4a). Arboreal elements became prominent since this interval, as the percentage of Betula and Ulmus increased at the expense of herbs like Artemisia, Poaceae and Thalictrum, which is the result of the intensification of the EASM.In the early Holocene from 11.8 to 10.8 ka BP, the vegetation type was still forest steppe while the extremely high pollen concentration throughout this interval suggests that the climate became significantly warmer and moister. The warmer and moister climate can be also inferred from the lake environment; the continued black-white lamina indicates a deep lake status. Moreover, the temperate deciduous broadleaved trees such as Betula and steppe Artemisia from meadow and other herbaceous taxa, whereas PCA axis 2 distinguishes steppe taxa from arborous and meadow taxa. This implies that the first principle component might mainly represent temperature with the taxa scores on the axis 1 positively related to cold conditions, and the second principle component might mainly represent humidity with the taxa scores on the axis 2 positively related to dry conditions. The first two axes capture most variance within the data set, which implies that the increasing of temperature is considered as the main factor of vegetation change from alpine meadow to forest steppe and the decreasing of humidity cause the vegetation change into steppe.The distribution of vegetation types is primarily determined by both temperature and moisture, therefore temperature and moisture could be semi-quantitatively estimated based on the ratios between groups of pollen taxa represented different temperature and moisture conditions –40. As mBased on above-mentioned, we tentatively define the ratio of temperature broadleaved and shrubs taxa to alpine meadow taxa as temperature index (T) and the ratio of arboreal pollen percentage to steppe taxa percentage as a moisture index (M). The detailed taxa for calculations of indices are listed in 18O record  at 14.4 ka BP, which corresponds to the start of Greenland Interstadial GI-1. Two temperate/warm phases, counterparts of Bølling (Zone 4a) and Allerød (Zone 4c) are characterized by higher or increasing proportions of temperate deciduous broadleaved trees to distinguish. They are separated by distinct and short cold phases with relative high herb contents, as Older Dryas (Zone 4b).18O values from Greenland ice core.The decrease in relative temperature calculated based on the pollen data of Lake Moon suggests a cold and dry event begins at ~12.8 ka BP. This major climate deterioration represented by Zone 5 is comparable with the Younger Dryas/GS-1 in the North Atlantic region, whose amplitude in East Asia appears much smaller than that in the North Atlantic region , which i14C data and the gradualness of vegetation response to climate change make it impossible to demonstrate absolute synchronous between the pollen records from Lake Moon and δ18O values from Greenland ice core. However, it is clear that cold and warm events found in the Lake Moon sediments can be roughly matched with corresponding climate events in ice cores in North Atlantic regions and Greenland, which have been proven to be controlled by the insolation of Northern Hemisphere and the meltwater pulse [The errors of age model based on er pulse ,53. If t18O records of caves from typical East Asian monsoon region with lower latitudes before B-A warming [Distinctly different trends are observed in relative temperature and humidity curves of Lake Moon . The dri warming –56. The The previous studies show that the sea level rises 20-30m during the B-A warming –59. The Different from H1-like event, YD-like event is suggested as a cold and dry event from Lake Moon occurring at ca. 12.8 ka BP. The drought during this period is consistent from coast to inland ,49,50, wThe pollen record from Lake Moon in the Great Khingan Mountain, Northeast China covers a time interval from 20.9 ka to 10.8 ka BP. It reveals six significant shifts in the vegetation: alpine meadow between 20.9 and 20.3 ka, dry steppe from 20.3 ka to 17.4 ka, alpine meadow again in the period of 17.4–14.4 ka and forest steppe since 14.4 ka within an expansion of steppe during 12.8–11.8 ka.The vegetation changes and reconstructed temperature and humidity index from the Lake Moon show distinct changes such as H1, B-A warming and YD events recorded in the North Atlantic. The onset of first deglacial warming of the study area was at ~20.3 ka BP, which synchronous with the decreasing of the global ice volumes and rising of the sea level. This warming trend is interrupted by H1-like event, which suggests that the shutdown of thermohaline circulation has a significant effect on the EASM. The B-A warming after H1-like event implies a drastic warming and wetting of the deglacial climate under strong EASM influence. The following YD-like event suggests declines of temperature and humidity caused by the weakening of EASM, while the temperature and humidity rise further in early Holocene because of the intensification of EASM once again.The pollen-based temperature reconstruction in the study area suggests that the change of ice volumes in high latitude region might play an important role, while the humidity could mainly be affected by the ocean conveyor belt circulation, teleconnected with the North Atlantic region after B-A warming.S1 Table(XLS)Click here for additional data file.


Surgical site infections (SSIs) remain a common and widespread problem contributing to a significant morbidity and mortality, attributed partly by the increase in antimicrobial resistance among the etiological agents. This study was done to determine the spectrum of bacterial isolates and their susceptibility patterns causing SSIs at Muhimbili National Hospital, Tanzania.This descriptive cross sectional study was conducted between September, 2011 and February, 2012. Pus swabs or pus were cultured on blood agar  and MacConkey agar  and incubated aerobically at 37°C for 18–24 hours. Bacterial identification was done using API 20E and VITEK and antimicrobial susceptibility was determined by Kirby Bauer disc diffusion.Pseudomonas aeruginosa (16.3%), followed by Staphylococcus aureus (12.2%) and Klebsiella pneumoniae (10.8%). Of the 18 S. aureus , 8 (44%) were methicillin resistant Staphylococcus aureus (MRSA) and three of them (17%) were carrying both MRSA and induced clindamycin resistance (ICR). Extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae were observed in 23 (79.3%) of the 29 isolates tested. Majority of Escherichia coli 12 (92.3%) and K. pneumoniae 11 (69%) isolates were ESBL producers. About 63% (93/147) were multiple-drug resistance (MDR) isolates, and the overall MDR among Gram positive and Gram negative bacteria was 60.6% (20/33) and 61.4%, (73/114), respectively. The prevalence of MDR for E. coli, A. baumannii and P. stuartii was 100% each. Majority (97%) of the Gram negative bacteria were resistant to more than four categories (classes) of antibiotics.Of the 100 patients, from whom wound swabs were collected, 90 (90%) had positive aerobic bacterial growth. A total of 147 pathogenic bacteria were isolated, including 114 (77.5%) gram negative and 33(22.5%) gram positive organisms. The most prevalent bacterial species were A high proportion (63%) of the isolates causing SSIs in this tertiary hospital were MDR, of which (90%) were resistant to more than four classes of antibiotics. In the light of these findings, an urgent and significant change in antibiotic prescription policy is required at this National hospital. Surgical site infections (SSI) remain a common and widespread problem that contributes to significant morbidity and mortality, prolongs hospital stay and consequently increasing health care cost . GloballStaphylococcus aureus was reported to be a predominant pathogen followed by Escherichia coli, and Klebsiella species with varying antimicrobial susceptibility patterns. A study at Bugando Medical Centre (BMC) reported resistance to ciprofloxacin of 86%, 80% and 54% for E. coli, Klebsiella pneumoniae and S. aureus respectively. Of the E. coli and K. pneumoniae involved in SSI at Bugando Medical Centre 65% and 80% were ESBL producers, respectively  . BrieflyS. aureus was detected by disc diffusion method on Mueller-Hinton Agar, where 15 μg of erythromycin disc and 2 μg of clindamycin disc were spaced 15 mm apart, incubated at 35 ± 2°C for 16–18 hours. Flattening of the zone of inhibition adjacent to erythromycin (D-zone) was interpreted as ICR [Escherichia coli ATCC 25922, K. pneumoniae ATCC 700603 for ESBL, S.aureus ATCC 25923, and S.aureus ATCC 29213 for MRSA.MRSA was determined by disc diffusion test using cefoxitin (30 μg) disc on Mueller –Hinton Agar, incubated and maintained at 33-35°C for 24 hours, zone of inhibition ≤ 21 mm was considered a positive result for MRSA strain . InducedMultidrug resistant (MDR) was defined as acquired non-susceptibility to at least one agent in three or more antimicrobial categories . AntimicData were entered and analyzed using Epidata Entry version 3.1 and STATA version 11.2, and expressed in a descriptive analysis. Categorical variables were compared using Chi-square test or fisher exact test, p values of < 0.05 was considered significant.Ethical approval was obtained from the Senate Research and Publications Committee of Muhimbili University of Health and Allied Sciences, Dar es Salaam and a written informed consent was obtained from each patient/caretaker.We enrolled a total of 100 patients with clinical SSI, aged between 18 and 80 years. Most of the patients (53%) were males and nearly half (46%) were from orthopedic and trauma wards. Regarding surgical procedures, 27% of the patients had surgical debridement and external fixation, 25% had laparotomy while 15% had caesarian section  of all bacterial isolates. K. pneumoniae 10.8% (16/147) and Proteus mirabilis 10.8% (16/147) were the next two common Gram negative organisms [Figure Escherichia coli and 11/16 (69%) of K. pneumoniae isolates were ESBLs producing strains. Of the Gram positive isolates, S.aureus was the leading cause of SSIs accounting 12.2% (18/147) of all isolates, followed by coagulase negative Staphylococci (6.8%) and Enterococcus faecalis (3.4%). Of the 18 S. aureus isolates, 44.4% (8/18) were MRSA strains and three of them had induced clindamycin resistance (ICR).Of the 100 wound swabs collected, 90% had bacterial growth. More than half  had pure bacterial growth (mono isolate). Gram negative organisms were more prevalent than gram positive bacteria accounting for 77.5% (114/147) of all isolates. The most predominant Gram negative organism was S. aureus isolates were highly resistant (83%) to penicillins group of antibiotic; some had low to moderate resistance (17% to 33%) to erythromycin, gentamicin and ciprofloxacin. All Enterobacteriaceae displayed high magnitude of resistance (69% to 100%) to multiple antibiotics tested but all were sensitive to meropenem; and 20-56% were resistant to ciprofloxacin. Surprisingly, 92% of 24 P. aeruginosa isolates were sensitive to both gentamicin and ciprofloxacin. Majority of A. baumannii isolates were highly resistant (73% to 100%) to most antimicrobial agents; however 60% of them appeared to be moderately sensitive to imipenem [Table Escherichiacoli, A. baumannii and P. stuartii, and 87.5% of Klebsiella spp. Surprisingly, only one isolate of the 24 P. aeruginosa displayed MDR [Table Most of sistance 7% to 33%Pseudomonas aeruginosa being the commonest followed by K. pneumoniae (10.8%) and Proteus mirabilis (10.8%). On the other hand S.aureus which was the commonest Gram positive organism accounted for (12.2%). This observation is in contrast to finding in previous studies from the same setting which reported Gram positive predominantly S. aureus as the most common SSI bacterial pathogen [This report on antimicrobial resistance from the national hospital in Tanzania demonstrates the predominance of gram negative bacterial isolates in SSIs 77.5%). Predominately 7.5%. Prepathogen   previously reported at this hospital in 2004/2010, [With regard to antimicrobial resistance we found, among Gram negative bacteria, very high levels of resistance (73 -100%) to commonly prescribed antibiotics like ampicillin, amoxicillin/clavulanic acid, co-trimoxazole and tetracycline, which is in keeping results (32 – 100%) reported in the same hospital and in Kenya ,20. The 04/2010, ,19. Resi04/2010, .E coli and K. pneumoniae being ESBL producing strains. These finding is in keeping with recent studies from Northern-Western Tanzania and Uganda that shows (61 – 92%) [With regard to third generation cephalosporins we found very high levels of resistance 67 -100%) among Gram negative bacteria, with most of  -100% am1 – 92%) . We noteEscherichia coli, Acinetobacter baumannii and Providentia stuartii were MDR strains.Significantly, we note an increasing trend of resistance to cotrimoxazole, gentamicin, ceftazidime and ciprofloxacin over a period from 2004 to 2012 Figures  and 4 11,19. In The very high levels of antibiotics resistance seen in this study could be attributed, at least in part, to inappropriate use of antimicrobial agents affects both the cost and efficacy, thus favoring the emergence of resistant bacteria.One of the limitations of our study is cross-sectional design of the study. Also there was no patient follow up after discharge up to 30 days which is required according to CDC definition of SSI and hence some cases of SSI after discharge from hospital may be missed.The very high levels of antimicrobial resistance among bacteria causing SSIs, including resistant to more than four categories (classes), complicates the management of these infections at MNH, and could be associated with higher SSI rate and prolongation of hospital stay and increased number of drugs usage. There is a very urgent need of revising the perioperative antimicrobial prophylaxis at this national referral Hospital to provide clinicians with standardized approach to the rational, safe and effective use of antibiotics management of SSI.The authors declare that they have no competing interests.JM participated in conception, design, and collection of data, analysis, interpretation and drafting of the manuscript. MIM helped to draft the manuscript. MM and SEM participated in critically revising the manuscript. SM participated in analysis and interpretation of data. EFL participated in conception, design of the study and critically revising the manuscript. All authors read and approved the final manuscript.Demographic and clinical characteristics of patients with post-operative wound infections.Click here for file


The prevalence of gestational diabetes (GD) in Brazil can exceed 18% when applied the current WHO diagnostic criteria. The importance of the GD treatment in reducing severe outcomes of perinatal maternal morbidity and has been shown in randomized clinical trials. Therapeutic options for the GD have included oral antidiabetic agents glibenclamide (GB) and metformin (MF) showed Results of safety and efficacy similar to insulin.To analyze the effects of the use of GB and MF in the treatment of GD in pregnant women at a specialized clinic in HCPA in a randomized open-label study.Eighty-one women diagnosed with GD and drug treatment indication were randomized. The initial dose of GB was 2.5 mg/day with an increase of 2.5 mg next week and new increments of 5 mg/week to achieve glycemic targets or maximum dose (20mg/day); MF is an initial dose of 500mg to 500mg increments every 3 days to obtain the target or maximum dose of 2.5 g/day.Thirty-six patients were randomized to the MT group and 45 for the GB group. The slurry treatment rate were 22.9% and 54.5%, respectively MP and GB group (p=0.006). Reasons for discontinuation of medications is hypoglycemia: 2.9% and 38.6% (p <0.001), respectively MF and GB group; not glycemic compensation: 2.9% and 13.6% (p=0.095), respectively MF and G groups); and gastric intolerance: 17.1% and 2.3% (p=0.021) respectively MF group and GB.Current evidence suggests that oral anti-diabetics are safe and effective for glycemic control in GD. This study was prematurely terminated by the high incidence of hypoglycemia in the GB group, considered ethically unacceptable by an independent review committee. MF was well tolerated and showed up as the first oral option in drug treatment of hyperglycemia in pregnancy.


Multivariate analysis confirmed EMVI as a significant independent prognostic indicator (p<0.001). In conclusion, the presence of EMVI as an independent prognostic indicator is shown and is related to other pathological and prognostic factors. This study emphasises the requirement for the accurate identification of EMVI in colorectal cancer excision specimens and also understanding the relationship of EMVI with other prognostic factors.Colorectal cancer is a common malignancy and a leading cause of cancer related death. Cancer staging following resection is key to determining any adjuvant therapy in those patients with high risk disease. In colorectal cancer, tumour stage and lymph node stage are the main pathological factors which have been considered to influence outcome. Increasing emphasis is now being placed on other factors, especially the presence of extramural venous invasion (EMVI). It is important to understand the relationship of EMVI with other pathological factors and to confirm that in an individual centre that EMVI is being detected at an appropriate rate and is of prognostic significance. This comprehensive study assesses the reporting and prognostic significance of EMVI in a single centre, using prospectively collected data from histopathology reports of a cohort of 2405 patients who underwent surgery for colorectal cancer over a nine year period. Overall, EMVI was reported in 27.9% of colorectal cancer excision specimens. In tumours (n = 1928) that had not received neoadjuvant therapy, the presence of EMVI varied significantly depending on tumour site (χ Colorectal carcinoma is the most common malignancy of the gastrointestinal tract and is a leading cause of cancer related deaths . PrognosWhilst not directly affecting overall tumour stage, the presence of EMVI does confer high risk disease status , 14. Indnd edition) published in 2007 recommended a frequency of detection of EMVI of 20% [Therefore, the United Kingdom Royal College of Pathologists (RCPath) has proposed a minimum rate of detection of EMVI in colorectal cancer excision specimens. This study reports on data collected from 2005 to 2013, during which time the RCPath dataset for colorectal cancer  and Dr Gray’s Hospital, Elgin  are both in NHS Grampian, while Balfour Hospital, Kirkwall (NHS Orkney) and Gilbert Bain Hospital, Lerwick (NHS Shetland) are both remote and rural hospitals. Approximately 75% of the colorectal cancer surgery is performed at Aberdeen Royal Infirmary. Relevant pathological data was extracted at the time of the weekly colorectal cancer multidisciplinary team meeting from the pathology reports of the resected colorectal cancer excision specimens and a database constructed.nd edition 2007–14) which incorporates guidance from TNM5 and all cases were also subject to multi-disciplinary review [The database was compiled using prospectively collected histopathological data from colorectal cancers resected between 2005 and 2013. The information recorded in this database includes age, gender, year of operation, administration of neoadjuvant therapy, whether the tumour was screen detected, tumour site, tumour differentiation, tumour (T) stage, the presence of EMVI, total number of lymph nodes examined, number of lymph nodes involved by metastatic tumour, lymph node (N) stage and Dukes’ stage. Information for each parameter was available for every patient. Additionally, survival data  was available for a subset of 1004 patients (number of deaths = 243). The histopathology of all the cases in this database were reported according to the criteria set out in the RCPath dataset for the reporting of colorectal cancer excision specimens  to perform data analysis. Statistical comparisons between groups were performed using chi-square (χ2) test. Survival curves were prepared using the Kaplan-Meier method with log-rank (Mantel-Cox) analysis. Multivariate analysis with Cox regression  was also performed.The database was compiled in Excel 2007 and then imported into IBM SPSS version 21 for Windows 7The project was carried out with ethics approval (ref. no. 08/S0801/81) from the North of Scotland research ethics committee. The research ethics committee did not require written participant consent and data was anonymised prior to analysis.The clinico-pathological parameters collected for the dataset are summarised in In this study, EMVI was reported in 27.9% of all colorectal cancer cases (n = 2405). EMVI was reported in 31.4% of cases where no neoadjuvant therapy had been received (n = 1928) compared with 13.4% in cases receiving neoadjuvant therapy (n = 477). Cases were subsequently grouped for analysis into those that had received neoadjuvant therapy or those that had not and cases that were screen detected or were not. Further subdivision into stage  and site of primary tumour was carried out for analysis.Tumours were grouped into the categories of proximal , distal  and rectum depending on their anatomical location.2 = 66.83, p<0.001) , the frequency of EMVI differed significantly depending on the primary tumour site. EMVI was reported in 35.0% of proximal, 29.0% of distal and 17.0% of rectum cases (χp<0.001) .2 = 12.03, p<0.005). For cases that had received neoadjuvant therapy (n = 477), the frequency of EMVI differed significantly depending on site of primary tumour. EMVI was reported in 25.0% of proximal, 50.0% of distal and 11.8% of rectum cases .In cases that had not received neoadjuvant therapy (n = 1928), the frequency of EMVI differed significantly depending on site of primary tumour. EMVI was reported in 35.0% of proximal, 28.0% of distal and 26.5% of rectum cases . Whereas, in screen detected cases (n = 328) EMVI reporting did not differ significantly between sites of primary tumour. EMVI was reported in 21.6% of proximal, 24.4% of distal and 24.7% of rectum cases .When cases that had not been screen detected were analysed (n = 2077) the frequency of EMVI differed significantly depending on site of primary tumour. EMVI was reported in 36.6% of proximal, 29.3% of distal and 15.2% of rectum cases   stage of primary tumour when all cases were considered. EMVI was reported in 1.8% of T0 , 0.7% of T1, 3.4% of T2, 27.6% of T3 and 56.9% of T4 tumours (χp<0.001) .2 = 268.188, p<0.001). For cases that had received neoadjuvant therapy, the presence of EMVI differed significantly depending on T stage of primary tumour. EMVI was reported in 1.8% of T0, 0% of T1, 3.0% of T2, 24.1% of T3 and 50% of T4 cases .In cases that had not received neoadjuvant therapy, EMVI was present in 0.9% of T1 tumours, 3.6% of T2 tumours, 28.2% of T3 tumours and 57.2% T4 tumours . There was also a significant difference in the frequency of EMVI depending on T stage of primary tumour in screen detected cases. EMVI was reported in 0% of T0, 2.6% of T1, 6.2% of T2, 31.1% of T3 and 51.6% of T4 cases .When cases that had not been screen detected were analysed, the presence of EMVI differed significantly depending on T stage of primary tumour. EMVI was reported in 2.1% of T0, 0% of T1, 2.6% of T2, 27.1% of T3 and 57.3% of T4 cases   stage of primary tumour. EMVI was reported in 14.9% of N0, 35.5% of N1 and 65.3% of N2, cases (χp<0.001) .2 = 294.368, p<0.001). When cases that had received neoadjuvant therapy are considered, there is also a significant difference in EMVI rate depending on N stage. EMVI was present in 7.2% of N0, 24.4% of N1 and 52.9% of N2 tumours respectively .In cases that had not received neoadjuvant therapy, there was a significant difference in EMVI rate depending on N stage, with EMVI present in 17.5% of N0, 37.2% of N1 and 66.6% of N2 tumours respectively . A significant difference in the frequency of EMVI depending on N stage was also seen in cases that had been screen detected, with EMVI present in 13.4% of N0, 34.9% of N1 and 55.6% of N2 cases respectively .Cases that were not screen detected showed a significant difference in EMVI rate depending on N stage, with EMVI present in 15.1% of N0, 35.6% of N1 and 66.4% of N2 tumours respectively   .2 = 253.753, p<0.001). In cases that had received neoadjuvant therapy, EMVI was reported in 0.8% of Dukes’ A cases, 17.9% of Dukes’ B cases and 33.6% of Dukes’ C cases .For cases that had not received neoadjuvant therapy EMVI was reported in 1.2% of Dukes’ A cases, 22.2% of Dukes’ B cases and 48.6% of Dukes’ C cases . For those cases that were screen detected, EMVI was reported in 3.7% of Dukes’ A, 21.4% of Dukes’ B and 41.7% of Dukes’ C tumours .In non-screen detected cases, EMVI was reported in 0.3% of Dukes’ A cases, 21.6% of Dukes’ B cases and 47.5% of Dukes’ C cases , Mantel-Cox log-rank test) . Of these, 190 (18.9%) cases had EMVI and 814 (81.1%) did not. When all cases were considered, EMVI reduced patient survival over time and these survival distributions were statistically different (χnk test) .2 = 113.741, p<0.001, HR = 0.241 .Survival data was available for 731 of the cases that had not received neoadjuvant therapy. Of these, 166 (22.7%) had EMVI and 565 (77.3%) did not. The presence of EMVI was associated with significantly reduced patient survival over time .Survival data was available for 273 of the cases that had received neoadjuvant therapy. Of these, 24 (8.8%) had EMVI and 249 (91.2%) did not. The presence of EMVI was associated with significantly reduced patient survival over time .When the cases of colon cancer that had not received neoadjuvant therapy (n = 653) were considered, 154 (23.6%) had EMVI and 499 (76.4%) did not. The presence of EMVI was associated with significantly reduced patient survival over time . Selection of rectal cancer cases that had received neoadjuvant therapy (n = 262) showed that 22 cases (8.4%) had EMVI and 240 cases (91.6%) did not. The presence of EMVI was associated with significantly reduced patient survival over time . A total of 78 rectal cancers had not received neoadjuvant therapy. Of these, 12 (15.4%) had EMVI and 66 (84.6%) did not. The presence of EMVI was associated with significantly reduced patient survival over time .When all rectal cancers (n = 306) were considered, EMVI was present in 34 (11.1%) and absent in 359 (89.9%) of cases. The presence of EMVI was associated with significantly reduced patient survival over time  , EMVI was present in 56 (15.1%) and not present in 316 (84.9%). The presence of EMVI was associated with significantly reduced patient survival over time (χnk test) .2 = 21.370, p<0.001, HR = 0.272 .For Dukes’ B cases that had not received neoadjuvant therapy (n = 301), 51 (16.9%) had EMVI and 250 (83.1%) did not. The presence of EMVI was associated with significantly reduced patient survival over time .Survival data was available for 71 Dukes’ B colorectal cancer cases that had received neoadjuvant therapy. A total of 5 (7.0%) had EMVI and 66 (93%) did not. The presence of EMVI was not associated with significantly reduced patient survival over time  , EMVI was present in 132 (33.0%) and not present in 267 (67.0%). The presence of EMVI was associated with significantly reduced patient survival over time (χnk test) .2 = 54.319, p<0.001, HR = 0.291 .For Dukes’ C cases that had not received neoadjuvant therapy (n = 319), 113 (35.4%) had EMVI and 206 (64.6%) did not. The presence of EMVI was associated with significantly reduced patient survival over time .Survival data was available in 71 Dukes’ C colorectal cancer cases that had received neoadjuvant therapy. A total of 19 (26.8%) had EMVI and 52 (73.2%) did not. The presence of EMVI was associated with significantly reduced patient survival over time . There were 638 non-screen-detected colorectal cancers that had not received neoadjuvant therapy. Of these, 147 (23.0%) had EMVI and 491 (77%) did not. The presence of EMVI was associated with significantly reduced patient survival over time . A total of 241 non-screen-detected colorectal cancer cases that had received neoadjuvant therapy were available for survival analysis. Twenty cases (8.3%) had EMVI and 221 cases (91.7%) did not. The presence of EMVI was associated with significantly reduced patient survival over time   had EMVI and 712 (81.0%) did not. The presence of EMVI was associated with significantly reduced patient survival over time (χnk test) .2 = 3.237, p = 0.072, HR = 0.384 . Within this group, 93 had not received neoadjuvant therapy. 19 (20.4%) had EMVI and 74 (79.6%) did not. There was no significant reduction in patient survival over time in this group .Of the bowel cancer screening detected cases in which survival data was available (n = 125), 23 (18.4%) had EMVI and 102 (81.6%) did not. In this group, EMVI was not associated with a significantly reduced patient survival over time  when other tumour dependent factors including tumour stage, lymph node stage, Dukes stage, tumour site and degree of tumour differentiation as well as patient specific factors of age and gender are considered Tables  and 3.EMVI was not a significant prognostic cofactor in screen detected cases but was in non-screen detected cases Tables  and 5.It is important for individual centres reporting colorectal excision specimen to demonstrate an appropriate frequency of detection of pathological prognostic factors taking account of confounding factors e.g. proportion of patients receiving neoadjuvant therapy and proportion of cases identified through a bowel cancer screening programme. Individual centres should also demonstrate that the pathological factors that are assumed to be prognostically significant are indeed prognostically significant in their population. This large study from a single centre utilises prospectively collected data to comprehensively assess the evaluation of EMVI in colorectal cancer resection specimens over a nine year period and to consider potential confounding factors including neoadjuvant therapy and the influence of bowel cancer screening. It uses a prospectively collected dataset to examine in detail the significance of the reporting of EMVI on mortality in this population. All of the data derives from a single histopathology department, thereby reducing data collection and reporting bias.There is well documented variation between centres in the demonstration of EMVI , 19–27. nd edition RCPath standard (20%) as well as the revised 3rd edition (2014) RCPath standard (30%) being surpassed [This study shows that when all cases are analysed, detection of EMVI exceeds the standard set by the Royal College of Pathologists over the same time period . In addiurpassed . Albeit As might be expected, EMVI is more common in higher stage  tumours and this study has demonstrated a stage dependent significant difference irrespective of whether the cases were screen-detected or not or if there had been neoadjuvant therapy or not. It has also shown the frequency of the identification of EMVI varied significantly depending on site of primary tumour when all cases, non-screen-detected cases, cases that had received neoadjuvant therapy and also those cases that had not. There was no significant tumour site dependent difference in the frequency of EMVI reporting in colorectal cancer cases that were detected by the bowel screening programme. It is not clear if that represent the smaller number of bowel cancer screening detected cases or reflects a difference in the biology between symptomatic colorectal cancer and screen detected cancers.Whilst the frequency of EMVI appears closely related to tumour stage, multivariate analysis has shown that EMVI is an independent predictor of poor prognosis, as are patient age and tumour stage. This study allowed assessment of all-cause mortality in a subgroup of patients. Overall, EMVI was associated with statistically significantly reduced survival. Only in screen-detected cases (n = 125) and in Dukes’ B cases following neoadjuvant therapy (n = 71) was EMVI not associated with a significant reduction in survival. However, this lack of significance may reflect the limited amount of survival data available in those groups.EMVI is clearly an important parameter with regards to patient prognosis and the post-operative management of colorectal cancer. Adequate reporting is therefore paramount and may be optimised with the use of ancillary techniques such as elastic haematoxylin and eosin staining , 20–23.


Cirrhotic patients admitted to the ICU are usually regarded as having a particularly poor prognosis when compared with other groups of critically ill patients. The aim of our study was to evaluate the prevalence, case mix and outcomes of patients with cirrhosis admitted to the general ICU of a nontransplant center.Data were collected from a running ICU database. We studied cirrhotic patients admitted to the ICU between January 2013 and November 2014.P < 0.05). The mortality rate of cirrhotic patients was superior to the general ICU mortality (43% vs. 26%). However, patients with cirrhosis presented significantly higher severity scoring systems  at admission compared with noncirrhotics, with high prevalence of organ dysfunction as assessed by SOFA score.A total of 30 patients with cirrhosis were admitted, accounting for 3% of total ICU admissions. Mean age was 54.5 years, with a male preponderance (76.7%). The main cause for cirrhosis was alcohol (53.3%), followed by alcohol plus chronic hepatitis C virus (HCV) infection (20%) and HCV virus infection alone (13.3%). The most common causes for admission were sepsis/septic shock (26.7%), surgical (23.4%), gastrointestinal bleeding and hepatic encephalopathy (16.7% each). At admission, these patients presented an average Model for End-Stage Liver Disease score of 23.5 ± 10.4 with 70% classified as grade C in the Child-Pugh score; mean Acute Physiology and Chronic Health Evaluation (APACHE II) 29.2 ± 8.7 and new Simplified Acute Physiology Score (SAPS II) 62.7 ± 29. Regarding organ failure at admission, the mean Sequential Organ Failure Assessment score was 12.8 ± 4.5. The ICU mortality of these patients was 43.3% and hospital mortality was 53.3%. The variables at admission that related significantly with ICU mortality were: all scores described except for Child-Pugh score, bilirubin, the International Normalized Ratio, creatinine, bicarbonate, lactate, pH and the use of renal replacement therapy during the ICU stay (The high severity of disease in conjunction with the high mortality rate observed in this group of patients should make us consider the possible benefits of earlier referring/admission to the ICU, ideally before multiorgan failure arises. On the other hand, in nontransplant centers where cirrhotic patients constitute a small percentage of total ICU admissions, the complexity and peculiarities of the management of these patients should prompt their early transfer to a specialized center.


This study investigates the correlation between SBP and repeated paracentesis, and its relation to MELD score, in cirrhotic patients with refractory ascites in an outpatient setting. Through the data base, 148 cirrhotic patients were prospectively included in the study with refractory ascites undergoing relief paracentesis from March 2012 to March 2013. Demographics data, etiology of liver disease, MELD score, and inscription on the waiting list for liver transplantation were analyzed. The ascites removed was analyzed through cellular count and culture for the diagnosis of spontaneous bacterial peritonitis. The cirrhotic patients underwent a total of 854 paracentesis procedures in the ambulatory setting during the study period. Eighty-one patients (54%) were on the waiting list for liver transplantation. Patients on the liver transplant list had higher associated costs due to a higher total number of outpatient paracentesis procedures (394.7 ± 512.3 versus 291.7 ± 384.7) and a higher volume drained per procedure (6.5 ± 8.5 versus 4.8 ± 6.4). There were 28 episodes of SBP (3.3%) diagnosed in 24 patients. In conclusion, the prevalence of asymptomatic SBP in cirrhotic patients with refractory ascites undergoing repeated paracentesis is low. MELD score is not related to spontaneous bacterial peritonitis. Ascites is the most common complication of cirrhosis –3. LargeCirrhotic patients are more likely to develop bacterial infections and spontaneous bacterial peritonitis (SBP), which is the most frequent and potentially lethal complication of ascites –3. The pMany factors are considered predisposing to the development of bacterial peritonitis in ascitic fluid. These risk conditions may be related to immunosuppression of the individual, increased intestinal permeability, bacterial growth in the small intestine , and an Approximately two-thirds of SBP cases are asymptomatic ; thus thThe aim of this study was to investigate the correlation between SBP and repeated paracentesis, and its relation to MELD score, in cirrhotic patients with refractory ascites in an outpatient setting.A number of 148 cirrhotic patients with refractory ascites who underwent paracentesis were followed up prospectively between the dates of March 2012 and March 2013 in the Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine (HCFMUSP), Brazil. The study included adults aged greater than 18 years who underwent outpatient paracentesis performed during the study period. The exclusion criteria were patients that did not want to participate in the study.In Brazil, the MELD score is used as a criterion for allocating liver transplantation. It is also reported as marker of prognosis of some complications of liver cirrhosis, such as gastrointestinal bleeding and SBP. It is known that the higher the MELD, the greater the severity of liver disease and, therefore, the greater the need of the individual undergoing liver transplantation.The MELD score was established after the determination of the calculation basis of this score as follows: INR, total bilirubin, creatinine, and sodium. After that the patients were divided into two groups for comparison of SBP development: patients in liver transplant waiting list and patients not listed for liver transplant. The patients listed for liver transplantation are those with MELD scores greater than or equal to 15 without contraindications, such as hepatobiliary metastasis or other organs; advanced cardiopulmonary disease; extrahepatic active infection; active alcoholism; drug abuse; being HIV positive; being positive for replication of hepatitis B virus; advanced chronic kidney disease.Therapeutic paracentesis relief is indicated in patients with respiratory distress from tense ascites.Paracentesis procedures are performed Monday through Friday from 7:00 to 16:00 at the HCFMUSP Clinic for Surgery and Liver Transplantation. Local anesthetic with lidocaine chloridrate 2% (Xylocaine) is used prior to paracentesis. The puncture is performed in the left iliac fossa or the suprapubic midline using a 14-gauge Jelco IV catheter. Volume replacement is accomplished with 20% human albumin 50 mL when greater than 2 liters of ascites volume is removed and 1 vial (50 mL) of albumin is replaced for every 2 liters of ascites fluid removed. Routine analysis of ascites fluid cytology for diagnosis of possible asymptomatic SBP is performed on all clinical samples. Only after positive results or clinical suspicion  liquid cultures are performed.Ascites fluid is collected in sterile bottles. The sample is centrifuged for 10 minutes and subjected to Giemsa staining techniques. Counts for the total number of polymorphonuclear cells are made by light microscopy. For bacterial culture, ascites fluid is inoculated into two blood culture bottles (each 10 mL) for aerobic and anaerobic analysis.3 regardless of the positivity of the bacterial culture [The diagnosis of SBP was established when the number of polymorphonuclear cells (PMN) was greater than or equal to 250 cells/mm culture . The immThis study was approved by the Ethics Committee of the Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil. Monetary values are expressed in US dollars. The values have been converted from Real to the Dollar according to the exchange in October, 2013, R $1 = US $$2.2.p value being <0.05.The results are described with mean and standard deviation. Median and range were used for currency values. Statistical analysis was performed using IBM-SPSS software version 20.0. Results were considered statistically significant with the A total of 148 patients with cirrhosis underwent a total of 854 paracentesis procedures in the ambulatory setting during the study period. The average patient age was 57 ± 11 years with a gender breakdown of 90 men (60.8%) and 58 women (39.2%). The average MELD score (Model for End-Stage Liver Disease) was 19.9 ± 8.45 .Patients underwent an average of 5.8 ± 7.8 paracentesis procedures/year. The total volume drained during one year was 7270.9 liters of ascites fluid and the average volume per patient was 8.4 liters. Fifty-two patients (35.1%) underwent only one paracentesis in the study period. During the study period, 28 (16%) died. In the patient population, the most common causes of cirrhosis were the following: viral hepatitis (B or C) (27%), alcohol cirrhosis (22.3%), and other causes (22.3%) .p = 0.075).We divided the patients into two groups. Eighty-one patients (54%) were on the waiting list for liver transplantation during the study period, which included 51 men (63%) and 29 women (37%), with average age 55.9 years ± 11.1. Thirty patients died (20.3%) in the period, 26 on the waiting list for liver transplantation and 4 outside of it. In both lists, there was predominance of male deaths (76.7%). This difference was not statistically significant (p < 0.001) (p = 0.075)  or the number of paracenteses performed (6.5 ± 8.5 versus 4.8 ± 6.4). Patients on the liver transplant list had higher associated costs due to a higher total number of outpatient paracentesis procedures ($391.7 range $210.3–$680.8 versus $282.7 range $156.6–$545.6), a higher volume drained per procedure (6.5 ± 8.5 versus 4.8 ± 6.4), and higher MELD score (22.9 ± 8.7 versus 14.8 ± 5.9). Additionally, there were more deaths during the study period in the patient group on the liver transplant list (30% versus 5.7%) compared to patients not on the transplant list (< 0.001) . The pat= 0.075) .There were 28 episodes of SBP (3.3%) diagnosed in 24 patients. Of these, 24 (85.7%) were asymptomatic SBP, while 4 were symptomatic, presenting one or more symptoms, such as fever, abdominal pain, hepatic encephalopathy, recent gastrointestinal bleeding, or worsening renal function.p = 0.012) and higher MELD score , although the SBP rate was not different . Thus, the development of SBP is not related to the MELD score, but instead it is related to the clinical status of the refractory ascites and the need of repeated paracentesis.The prevalence of SBP in asymptomatic cirrhotic patients is low. Our study showed that the occurrence of SBP is not related to the severity of liver disease evaluated by MELD score. Repeated paracentesis is still a good palliation for refractory ascites until the definitive treatment with liver transplant.


DXA and BF%BIA8, respectively. A one-way ANOVA was used to test the differences in BF% measurements by gender and levels of adiposity. The estimated BF%BIA8 and BF%DXA in the all subjects, male and female groups were all highly correlated . The average estimated BF%BIA8 (22.54 ± 9.48%) was significantly lower than the average BF%DXA (26.26 ± 11.18%). The BF%BIA8 was overestimated in the male subgroup (BF%DXA< 15%), compared to BF%DXA by 0.45%, respectively. In the other subgroups, the BF%BIA8 values were all underestimated. Standing BIA estimating body fat percentage in Chinese participants have a high correlation, but underestimated on normal and high obesity degree in both male and female subjects.Bioelectrical impedance analysis (BIA) is a common method for assessing body composition in research and clinical trials. BIA is convenient but when compared with other reference methods, the results have been inconclusive. The level of obesity degree in subjects is considered to be an important factor affecting the accuracy of the measurements. A total of 711 participants were recruited in Taiwan and were sub-grouped by gender and levels of adiposity. Regression analysis and Bland-Altman analysis were used to evaluate the agreement of the measured body fat percentage (BF%) between BIA and DXA. The BF% measured by the DXA and BIA methods (Tanita BC-418) were expressed as BF% The prevalence of overweight and obesity has increased tremendously in the global population . ObesityIn recent years, the measurement protocol of BIA has changed from the traditional supine position with disposable contact electrodes to the standing up position with reusable stainless steel plates as electrodes , 8. MostSeveral studies have compared the BF% results as assessed by BIA with other referenced methods –11, and We further compared the differences between the sexes and among different adiposity level subgroups to verify whether the BIA measurement is biased by the levels of adiposity of the Chinese subjects.Test subjects were selected by a non-random purposive sampling method. The 711 subjects were recruited voluntarily from different locations in Taiwan through advertisements. The subjects were asked to complete health history questionnaires, including personal information, physical characteristics and health conditions. The subjects were further asked to refrain from alcoholic drinks 48 hours prior to the test, from diuretics 7 days prior, and from strenuous physical activities 24 hours prior. Subjects were to void urinary bladder and after a fast > 1.5 h to the experiment. Health questionnaires were distributed to all participants and no test subjects reported any endocrine disorder, nutritional or growth disorders or major chronic conditions, such as diabetes, cancer, kidney dysfunction, asthma and electronic implants, such as an artificial heart or electrodes. Female participants were excluded from measurements if pregnant or during menstruation cycle. The measurements were carried out in the Taichung County Dali Jen Ai Hospital, radiology department. The experimental procedure and research plan were approved by the board of clinical trials of the Jen Ai Hospital (IRB 97–01). All subjects were recruited and signed an informed consent before participating in the study.8 denoted in text) to the nearest 0.1 kg. Subjects’ height was measured without shoes by a Stadiometer to the nearest 0.5 cm and body mass index (BMI) was calculated was calculated as weight divided by height squared (kg/m2). The intraexaminer coefficient of variation was 3.6%.Each subject was weighed using a Tanita BC-418 . BF% was calculated as fat mass / (fat mass + fat free mass) × 100%. The fat-free mass (FFM) is the sum of the measured total fat-free tissue mass and the bone mineral content. DXA was completed by the Encore 2003 Version 7.0 analytical software. DXA measurements were taken at 2:00 pm each day, and once the DXA measurements were completed, BIA was conducted immediately afterwards. All DXA and BIA8 to measure the impedances of the body and of each limb in the standing position. Subjects were asked to hold an electrode shaped like a hand grip in each hand and to stand on base plate electrodes. The electrodes allowed a current to pass through the subject's body and impedance was further measured. The impedances were measured via the pathway from the left foot to the left hand. These impedance measurements were used to estimate the BF%, adjusting for other physical parameters, such as height, weight, age and sex. The BF%, as measured by the DXA and BIA methods, was expressed as BF%DXA and BF%BIA8, respectively.We used the BIAt-test was used to compare the difference in BF%BIA8 and BF%DXA, Pearson’s correlation, Lin’s concordance correlation coefficient (ρc) [BIA8 and BF%DXA [P < 0.05. The Bland-Altman analysis was used to test the agreement between BF%BIA8 and BF%DXA [BIA8 and BF%DXA within the different BF% subgroups. We categorised subjects according to the measured adiposity level into: lean, normal and obese categories [DXA as the x-axis and FFMBIA8 –FFMDXA as the y-axis, and regression analysis was conducted. All statistical analyses were conducted using SPSS for Windows  and Medcalc .In this study, values are expressed as the mean ± SDs. The paired ent (ρc)  and ordid BF%DXA . Statistd BF%DXA . Additiotegories . Scatter2.The physical characteristics of the subjects are listed in 8 and DXA are listed in BIA8 and BF%DXA were 22.54 ± 9.48% and 26.26 ± 11.18% respectively. The measured BF%BIA8 was significantly lower than BF%DXA in both male and female subjects. The correlation coefficient between BF%BIA and BF%DXA for all subjects was calculated as 0.93, while for the male and female subgroups, they were 0.90 and 0.92, respectively.  uncategorised, including all subjects, (ii) categorised into lean, normal and obese subgroups. The results are shown in The Bland-Altman analysis was used to test the agreement between BF%DXA and BF%BIA8 across all subjects, and the bias ± SD between the two results was -3.72 ± 4.09%. DXA: <20% (n = 212), normal—BF%DXA: 20%-30% (n = 229) and obese—BF%DXA: >30% (n = 270) subgroups. BF%BIA8 underestimated BF % compared to BF%DXA in the lean, normal and obese subgroups by -0.40± 3.31%, -4.13 ± 3.42% and -5.98 ± 3.42%, respectively.DXA and BF%BIA8 across all male (n = 412) subjects, and the bias ± SD between the two results was -3.66 ± 4.24%. DXA:< 15% (n = 135), normal- BF%DXA: 15%-25% (n = 129) and obese- BF%DXA:>25% (n = 148) subgroups. BF%BIA8 overestimated BF% compared to BF% DXA in the lean subgroups by 0.45± 2.76%, but it underestimated BF% in the normal and obese subgroup by -4.01 ± 2.77% and -7.01 ± 3.11%, respectively.DXA and BF%BIA8 across all female subjects (n = 299), and the bias ± SD between the two results was -3.81 ± 3.87%. DXA: < 25% (n = 64), normal—BF%DXA: 25%–33% (n = 78) and obese -BF%DXA > 33% (n = 157) subgroups. BF%BIA8 underestimated BF% compared to BF%DXA in lean, normal and obese subgroups by -0.15± 3.23%, -3.35 ± 2.91% and -5.53 ± 3.42%, respectively.BIA8 and BF%DXA in male and female subject. Other subgroup all showed proportional and/or fixed bias (ρc) are shown in ρc: Value of ρc < 0.90 is poor and 0.90 to 0.95 is moderate. In ρc value were less than 0.09.When focus on the different levels of adiposity subgroups in male and female subjects and applying linear regression analysis to the data, the result showed no fixed and proportional bias from the slope and intercept 95%CI between BF%xed bias . Lin’s cDXA according to FFMBIA8 and FFMDXA differences.8 and DXA methods in a large sample of a healthy Chinese population in Taiwan. The results of the study showed that using BIA8 to estimate BF% yields results that are similar to those of the DXA method in both male and female subjects. Sun et al. compared the BF%DXA with an estimated BF% in a supine posture BIA with multiple frequencies in a large healthy Canadian population and attained similar results. However, according to the results of our study, BF%BIA8 had a higher correlation with BF%DXA than BF% did when estimated by a supine posture BIA [The use of Tanita BC-418 for estimating and validating body composition has been reported in numerous studies –26, but ture BIA .8 against that by DXA and examined the trend line between the two measurements; and 4. Use different genders, obesity level, analysing the DXA proportional bias and fixed bias results.Body composition information can be applied in clinical trials and other medicine-related fields , 28. SomThe manufacturers of the currently available BIA measuring equipment have not released their built-in prediction equations or identified a suitable testing population, which limits the reference and application value of BIA . This woBIA8 and BF%DXA, which is consistent with other research [BIA8 and BF%DXA by the Bland-Altman analysis, the results show that for mixed, male and female sample sets, BF%BIA8 underestimates BF% compared to BF%DXA, but the differences do not deviate with statistical significance .This research shows that a high degree of correlation exists between BF%research , 17. A hresearch , 21. AftDXA. Sun et al. used the Bland-Altman analysis to investigate the differences between supine posture BIA and DXA measurements of BF% according to sex and adiposity, and they also categorised subjects into total, male and female, as well as lean, normal and obese [8 compared to DXA, and the degree of the bias also increased as the BF%DXA increased. These results are consistent with the BF% of obese women measured by the Tanita BC-418, as reported by Neovius et al. [et al. used different race, age and obesity level to estimate BF% between Tanita BC-418 and DXA measurements. At the end, the authors reported that BC-418 have underestimated BF% than of DXA measured results [The Bland-Altman analysis is usually used to explore variables without categorising or splitting the sample so that the agreement between two measurement methods may be analysed. However, this research examined the distributions and trends of the measured differences not only by splitting the sample into male and female subgroups but also by categorising them according to their measured BF%nd obese . Althougs et al.  Studied  results –26.et al. stated that a standing hand-to-foot BIA is a stable and suitable method for assessing whole body BF%, and the variation of within-day impedance measurements determined by standing hand-to-foot BIA was smaller than the variation of those determined by standing hand-to-hand or foot-to-foot BIAs [Oshima oot BIAs . Additiooot BIAs .A distinct measuring difference was found when it comes to the DXA apparatus designed by different manufactories. The evaluated BF% data measured from the Hologic QDR series were always higher than that of Lunar DPX series . In lowe8 and DXA to examine the measurement differences with in various BF% subgroups. In both male and female subjects except for subjects with adiposity lower than normal levels, BIA8 has the tendency to underestimate BF%. These differences increase with the level of adiposity; BIA8 overestimated BF% in the low BF% group and underestimated BF% in the high BF% group. These findings are similar to the trend reported by previous supine posture BIA study [This study used parallel measurements of BF% by hand-to-foot BIAIA study . In the 8 may generate inaccurate measurements when subjects with high adiposity and when applying measurements to the Chinese population, as participants’ adiposity levels increases, BF% will increase its underestimation correspondingly.In summary, BIA


In a cohort study, Beate Karges and colleagues find that the association between low hemoglobin A1C and severe hypoglycemia in children and young adults with type 1 diabetes has decreased over the period between 1995 and 2012.Please see later in the article for the Editors' Summary Severe hypoglycemia is a major complication of insulin treatment in patients with type 1 diabetes, limiting full realization of glycemic control. It has been shown in the past that low levels of hemoglobin A1c (HbA1c), a marker of average plasma glucose, predict a high risk of severe hypoglycemia, but it is uncertain whether this association still exists. Based on advances in diabetes technology and pharmacotherapy, we hypothesized that the inverse association between severe hypoglycemia and HbA1c has decreased in recent years.p<0.001) and 1.9%  each year, respectively. Risk reduction of severe hypoglycemia and coma was strongest in patients with HbA1c levels of 6.0%–6.9% (RR 0.96 and 0.90 each year) and 7.0%–7.9% (RR 0.96 and 0.89 each year). From 1995 to 2012, glucose monitoring frequency and the use of insulin analogs and insulin pumps increased (p<0.001). Our study was not designed to investigate the effects of different treatment modalities on hypoglycemia risk. Limitations are that associations between diabetes education and physical activity and severe hypoglycemia were not addressed in this study.We analyzed data of 37,539 patients with type 1 diabetes  from the DPV (Diabetes Patienten Verlaufsdokumentation) Initiative diabetes cohort prospectively documented between January 1, 1995, and December 31, 2012. The DPV cohort covers an estimated proportion of >80% of all pediatric diabetes patients in Germany and Austria. Associations of severe hypoglycemia, hypoglycemic coma, and HbA1c levels were assessed by multivariable regression analysis. From 1995 to 2012, the relative risk (RR) for severe hypoglycemia and coma per 1% HbA1c decrease declined from 1.28 (95% CI 1.19–1.37) to 1.05 (1.00–1.09) and from 1.39 (1.23–1.56) to 1.01 (0.93–1.10), respectively, corresponding to a risk reduction of 1.2%  in the blood. Blood sugar levels are usually controlled by insulin, a hormone produced by the pancreas. In people with diabetes, blood sugar control fails because they make no insulin (type 1 diabetes) or because the cells that normally respond to insulin by removing sugar from the blood have become insulin-resistant (type 2 diabetes). Type 1 diabetes, which tends to develop in childhood or early adulthood, is responsible for about 10% of cases of diabetes in adults and is treated with injections of insulin. Type 2 diabetes can usually be treated with diet, exercise, and antidiabetic drugs. With both types of diabetes, it is important to keep blood sugar levels within the normal range (good glycemic control) to reduce the long-term complications of diabetes, which include kidney failure, blindness, and an increased risk of cardiovascular disease.Patients with type 1 diabetes can achieve strict glycemic control using intensive insulin therapy, but such treatment is associated with a risk of severe or fatal hypoglycemia (low blood sugar). Past studies have found an association between low levels of hemoglobin A1c  and a high risk of severe hypoglycemia. Because of this inverse association, people at risk of severe hypoglycemia are advised to aim for an HbA1c of 7.5% or less, which puts them at risk of diabetic complications . With recent improvements in insulin therapy, it is not clear whether the inverse association between the incidence of severe hypoglycemia and HbA1c levels still exists. In this trend analysis, the researchers investigate the association over time between HbA1C levels and the risk of severe hypoglycemia in a large cohort (group) of Austrian and German children and young adults with type 1 diabetes.The researchers analyzed data on Hb1Ac levels and on incidents of severe hypoglycemia and hypoglycemic coma collected from 37,539 children and young adults with type 1 diabetes between 1995 and 2012 by the DPV (Diabetes Patienten Verlaufsdokumentation) Initiative for diabetes care. The DPV cohort includes around 80% of all children and young adults with type 1 diabetes in Germany and Austria. Over the study period, the use of insulin analogs (compounds related to insulin that keep blood sugar levels steadier than regular insulin injections) and of insulin pumps  increased, and there was an increase in how often patients monitored their blood sugar level. Notably, between 1995 and 2012, the relative risk for severe hypoglycemia per 1% decrease in Hb1Ac declined from 1.28 to 1.05, and the relative risk for hypoglycemic coma per 1% decrease in Hb1Ac declined from 1.39 to 1.01. That is, the strength of the inverse association between severe hypoglycemia or coma and HbA1c decreased during the study period. Expressed another way, between 1995 and 2012, the relative risk for severe hypoglycemia and coma per 1% HbA1c decrease dropped by 1.2% and 1.9%, respectively, each year.These findings reveal a substantial decrease since 1995 in the previously strong inverse association between low HbA1c levels and severe hypoglycemia and hypoglycemic coma in this cohort of young Germans and Austrians with type 1 diabetes. This decrease mainly occurred because of substantial reductions in the risk of hypoglycemia in patients with HbA1c levels between 6.0% and 7.9%, but the study provides no information about the drivers of this reduction. Moreover, these findings may apply only to young type 1 diabetes patients of European descent, and their accuracy may be limited by other aspects of the study design. However, by showing that HbA1c has become a minor predictor for severe hypoglycemia in this group of patients, these findings suggest that strict glycemic control in young patients with type 1 diabetes has become safer in recent years. Thus, it should now be possible to reduce the risk of long-term diabetic complications in such patients through achievement of near-normal glycemic control without increasing patients' risk of severe hypoglycemia.http://dx.doi.org/10.1371/journal.pmed.1001742.Please access these websites via the online version of this summary at US National Diabetes Information Clearinghouse provides information about diabetes for patients, health care professionals, and the general public (in English and Spanish), including information on the HbA1c test and a description of a trial that compared the effects of intensive versus conventional treatment of blood glucose levels on the development of diabetic complications in patients with type 1 diabetesThe type 1 diabetes, including a video that describes parents' experiences caring for a child with type 1 diabetes, and information about treating type 1 diabetes that includes a short video about HbA1cThe UK National Health Service Choices website provides information for patients and carers about Diabetes UK provides detailed information about type 1 diabetes for patients and carersThe charity type 1 diabetes and young people, including interviews with young people about their experiences of the conditionThe UK-based non-profit organization Healthtalkonline provides information about type 1 diabetes (in English and Spanish)MedlinePlus provides links to further resources and advice about DPV Initiative is available (mainly in German)Information about the  Maintenance of near-normal glycemic control is a central goal for individuals with diabetes to reduce diabetic complications of the eye, kidney, nerves, and cardiovascular system A strong inverse association between the incidence of severe hypoglycemia and hemoglobin A1c (HbA1c) levels has been described in previous decades in adults The aim of this study was to investigate temporal trends in the association between severe hypoglycemia (defined as an event requiring assistance of another person) and HbA1c levels in a large cohort of young patients with type 1 diabetes. We have previously shown that the use of insulin analogs and continuous subcutaneous insulin infusion (insulin pump) has increased during the past decade in these patients Informed consent for participation in the DPV Initiative was obtained from patients or their parents by verbal or written procedure, as approved by the responsible commissioners for data protection of each participating center. Analysis of anonymized data within the DPV Initiative was approved by the Ethics Committee of Ulm University, Ulm, Germany.n = 53,474 eligible patients. Exclusion criteria were diabetes duration less than 2 y , HbA1c <6% (<42 mmol/mol) (n = 715), comorbid celiac disease , and place of birth of one or both parents outside Germany or Austria . For each patient, clinical data  were averaged per year of follow-up, and numbers of hypoglycemic events were added up. Thus, the analysis dataset originated from independent cross-sectional cohorts of patients by calendar year.The DPV (Diabetes Patienten Verlaufsdokumentation) Initiative in Germany and Austria has prospectively followed patients with diabetes mellitus since January 1, 1995 Severe hypoglycemia was defined according to the American Diabetes Association Workgroup on Hypoglycemia In order to adjust for different laboratory methods , local HbA1c values were mathematically standardized to the Diabetes Control and Complications Trial (DCCT) reference range 4.05%–6.05% using the multiple-of-the-mean transformation method Rates of severe hypoglycemia and coma were expressed per 100 patient-years with 95% CIs based on normal approximation of the Poisson distribution. For descriptive analysis, mean and SD were calculated for continuous variables, and percentages for categorical variables. Mean rates of severe hypoglycemia and coma were compared between years of treatment based on a Poisson distribution of events.To assess the effect of potentially influencing factors on the rate of severe hypoglycemia and hypoglycemic coma, multivariable negative binominal regression analysis was conducted in order to account for over-dispersion of events. To analyze trends in the rate of severe hypoglycemia, models including year of treatment as an independent continuous term were fitted, with adjustments for HbA1c, sex, age, diabetes duration, and insulin treatment regimen . To assess the association between HbA1c and the rate of severe hypoglycemia, models including HbA1c as a continuous term were fitted, with adjustments for sex, age, diabetes duration, and insulin treatment regimen. To investigate trends in the associations between HbA1c, sex, age, and diabetes duration and the rate of severe hypoglycemia, the year of treatment and terms for interaction between these variables and year of treatment were included in the regression models. In additional analyses, HbA1c  was modeled as a categorical effect. Results of regression analyses are presented as mean adjusted rates or relative risks (RRs) including 95% CIs. Wald tests were used for hypothesis testing. p-Values of two-sided tests <0.05 were considered statistically significant. All analyses were performed with SAS for Windows, version 9.3 (SAS Institute).p<0.001). Diabetes duration decreased from 8.1±4.2 y in 1995 to 5.9±2.8 y in 2012, with an average annual decrease of 0.084±0.003 y . There was no temporal trend in the sex distribution of the study population from 1995 to 2012 .The entire study population consisted of 37,539 individuals  with a mean age ± SD of 14.4±3.8 y from 349 diabetes centers (listed in p<0.001). The percentage of individuals using insulin pumps continuously rose from 1.3% in 1995 to 47% in 2012, with an average absolute annual increase of 3.2%±0.04% . Total daily insulin dose per kilogram showed a very small but significant increase over time . Mean prandial-to-total-insulin ratio was 0.5±0.2 in each year before 2003 and 0.6±0.2 in each year after 2004 .The average number of HbA1c measurements per patient per year was 3.2±1.8. In total, 118,811 HbA1c measurements were available for analysis. Mean HbA1c decreased from 8.9%±1.8% (74±15 mmol/mol) in 1995 to 8.0%±1.3% (64±13 mmol/mol) in 2012, with an average annual decrease of 0.036%±0.002% . The proportion of individuals using long-acting insulin analogs increased from 1.3% in 2000 to 41.7% in 2012, with an average annual increase of 2.5%±0.05% . The mean frequency of SMBG per day continuously increased from 2.8±1.4 per day in 1995 to 5.5±1.9 per day in 2012, with an average annual increase of 0.11±0.002 per day . A total of 6,517 events of severe hypoglycemia in 3,372 patients (9.0% of patients) and 1,169 events of hypoglycemic coma in 897 patients (2.4%) were documented of 155,240 medical visits.The proportion of patients using short-acting insulin analogs continuously increased from 4.3% in 1996 to 74.6% in 2012, with an average annual increase of 4.3%±0.04%  and 0.92 , respectively, after adjustment for sex, age, and diabetes duration. This corresponds to a reduction in severe hypoglycemia and coma of 2% and 8% per consecutive year, respectively. Results were similar after additionally adjusting for insulin treatment regimen, with RR per year of 0.99  and 0.92 , respectively.The unadjusted mean rates of severe hypoglycemia and hypoglycemic coma within the whole observation period between 1995 and 2012 were 20.07 per 100 patient-years (95% CI 19.59 to 20.57) and 3.60 per 100 patient-years (95% CI 3.40 to 3.81), respectively. Mean rates of severe hypoglycemia and coma declined from 42.28 per 100 patient-years (95% CI 33.56 to 53.27) and 13.51 per 100 patient-years (95% CI 8.98 to 20.33) in 1995, respectively, to 17.63 per 100 patient-years (95% CI 16.92 to 18.37) and 1.82 per 100 patient-years (95% CI 1.60 to 2.06) in 2012, respectively. From 1995 to 2012, there was a significant decrease in severe hypoglycemia and hypoglycemic coma, as calculated by regression analysis, with RR per 1 y of 0.98 . These results remained significant after additional adjustment for insulin treatment regimen .To study the link between HbA1c and severe hypoglycemia or coma over time, trends in RRs for the period 1995 to 2012 were calculated by regression analysis, adjusted for age, sex, and diabetes duration. From 1995 to 2012, the RR for severe hypoglycemia and hypoglycemic coma per 1% HbA1c decrease declined from 1.28 to 1.05 and from 1.39 to 1.01, respectively , indicatThe RRs for severe hypoglycemia and hypoglycemic coma were also analyzed by HbA1c category for each year from 1995 to 2012 by regression analysis . The redDuring the entire observation period from 1995 to 2012, older age was associated with moderately decreased risk of severe hypoglycemia  has markedly decreased in the recent decade until 2012 (RR per 1% HbA1c decrease 1.05). Thus, HbA1c has become a minor predictor for severe hypoglycemia in young patients with type 1 diabetes. This effect was caused by a substantial reduction of hypoglycemia risk from 1995 to 2012 exclusively in patients with HbA1c levels of 6.0%–6.9% and 7.0%–7.9% (50% risk reduction). Similarly, the risk of hypoglycemic coma decreased preferentially in patients in low HbA1c categories .Our finding of a significant decline in hypoglycemia and coma rates in patients with low HbA1c during recent years is consistent with previous observations in smaller population-based studies Hypoglycemia risk may be affected by a variety of treatment-related factors, including type of insulin, route of insulin administration, and SMBG frequency Other predictors of severe hypoglycemia identified in this study were younger age, longer diabetes duration, and female sex, in line with previous studies A strength of this study is its large, population-based multicenter database with prospective documentation of “real-life” diabetes care, suitable for analyzing temporal trends over almost two decades Our data may have potential implications for the clinical management of patients with type 1 diabetes. Lower HbA1c and hypoglycemia have been traditionally viewed as two sides of one coin, a notion that is supported by the data from the early years of observation in our study, as well as by other reports In conclusion, the results from this study show that the former association between the risk of severe hypoglycemia and low HbA1c levels has largely decreased during the last decade in young patients with type 1 diabetes. Thus, in Germany and Austria, low HbA1c is no longer a strong predictor of severe hypoglycemia in young patients with type 1 diabetes, reducing the barriers to achieving and maintaining near-normal glycemic control.Text S1Participating DPV centers.(DOCX)Click here for additional data file.Text S2STROBE checklist.(DOC)Click here for additional data file.


P. falciparum, S. mansoni and soil transmitted helminths (STH) infections and their correlation with schoolchildren’s anemia in the Democratic Republic of Congo (DRC), we collect these data.Anaemia reduces cognitive potential in school children, retards their growth and predisposes them to other diseases. As there is a paucity of data on the current burden of S. mansoni and STH infections were assessed using kato-katz technique. Malaria infection and hemoglobin concentration were assessed using Blood smear and Hemocontrol device, respectively.This study reports baseline data collected from a randomized controlled trial investigating the impact of IPT with SP and SP-PQ on anemia and malaria morbidity in Congolese schoolchildren . Plasmodium spp. infection was 18.5% (95%CI:15.6–21.9). Amongst those infected, 24 (21%), 40 (35.1%), 40 (35.1%), 10 (8.8%), had light, moderate, heavy, very high malaria parasite density, respectively. Above 9 years of age (p = 0.02), male and history of fever (p = 0.04) were both associated with malaria infection. The overall prevalence of S. mansoni infection was 6.4% (95%CI:4.4–9.1). Girls were associated with S. mansoni infection (p = 0.04). T. trichiura was the most prevalent STH infection (26.3%), followed by A. lumbricoides (20.1%). Co-infection with malaria-S. mansoni and malaria-STH was, respectively, 1.5% (CI95%:0.7–3.3) and 6.4% (CI95% 4.4–9.1). The prevalence of anemia was found to be 41.6% (95%CI:37.7–45.6) and anemia was strongly related with Plasmodium ssp infection  and S. mansoni infection .A total of 616 primary schoolchildren from 4 to 13 years old were enrolled in the study. The prevalence of S. mansoni infection were strongly associated with high prevalence of anemia in schoolchildren. Therefore, specific school-based interventions, such as intermittent preventive treatment or prophylaxis, LLITN distribution, anthelminthic mass treatment and micronutrient supplementation are needed to improve school children’s health.Malaria and  P.falciparum, schistosomiasis and STH infections have been reported from various epidemiological settings in Africa Malaria, Schistosomiasis and Soil Transmitted Helminth (STH) infections compose a considerable disease burden in schoolchildren in developing countries. These parasitic infections show a similar geographic distribution and polyparasitism of P.falciparum triggers the development of acquired immunity that controls blood-stage parasitaemia, thereby reducing clinical symptoms and life-threatening complications in older children and adults Plasmodium infections, if untreated, persist and maintain malaria-induced inflammation that is commonly associated with iron deficiency anaemia (IDA) due to impaired intestinal iron absorption, impaired iron release from hepatocytes, and impairment of the recycling of iron derived from phagocytosis of parasitized red blood cells In endemic malaria areas, the prolonged carriage of P. falciparum, Schistosomiasis and/or STH infection on childhood anemia has been reported Findings on the interaction of malaria and helminth infections on the health of children are controversial. Some studies have shown a protective effect of helminths on symptomatic malaria. Severe worm burden seems to suppress malaria symptoms The Democratic Republic of Congo (DRC) is at present one of the most affected countries by malaria P. falciparum, Schistosomiasis and STH infections, or their relationship with anemia in primary schoolchildren. The aim of this study was therefore to determine the prevalence of asymptomatic malaria, Schistosomiasis and STH infections in apparently healthy children attending schools in a semirural area in Kinshasa, DRC, as well as their relationship with anemia.While a hand full of studies are dedicated to the groups most vulnerable for malaria such as children under the age of five and pregnant women, very little is known about the ongoing burden of asymptomatic Kinshasa is one of the biggest cities in Africa and divided into 25 administrative zones or municipalities that cover about 9,965 km2. According to the national health policy, 25 Health Zones (HZs) roughly cover the 25 administrative zones. These HZs are also divided into Health Areas (HAs). Kimbanseke is the most densely populated peripheral municipality of Kinshasa housing 946, 372 inhabitants in 2004 This study analyses cross-sectional, baseline data from an open label, randomised, controlled trial enrolling asymptomatic school children and investigating the impact of intermittent preventive treatment (IPT) with Sulfadoxine-Pyrimethamine (SP) and SP plus Piperaquine (PQ) on anemia and malaria morbidity in Congolese schoolchildren . The trial design and protocol are described in detail elsewhere th to the 24th November 2012. Children whose parents did not provide written informed consent or presenting fever, muscle aches or other symptoms suggestive for malaria at the time of enrolment were excluded. Children participating in another clinical trial were also excluded from the study. A structured questionnaire was used to obtain information on age, river contact, history of fever, diarrhea and abdominal pain.Briefly, asymptomatic primary school children were recruited from the 10Plasmodium infection using microscopic examination for malaria parasites. Giemsa-stained thick blood smears (TBS) were used for microscopy. Blood slides were examined using light microscopy at 1000 × magnification. Hundred microscopic fields were examined in the thick smear before concluding that a blood slide was negative. All slides were read twice by experienced microscopists. If the discrepancy was greater than 15%, a third reader was used to confirm diagnosis. The parasite density per microliter of blood was calculated using the following formula: (Number of trophozoites x 8000)/Number of leucocytes. Parasite counts were utilized to classify the intensity of Plasmodium spp. infection into light, moderate, heavy, or very heavy infections respectively as followed: 1–499 parasites/µL, 500–1,999 parasites/µL, 2,000–9,999 parasites/µL and ≥10,000 parasites/µL.Finger-prick blood specimens were taken for analysis of S. mansoni and/or helminth eggs were counted and the number obtained was multiplied by the factor 24 in order to get the number of eggs per gram of feces (epg). Egg counts were utilized to classify infection intensities into light, moderate, or heavy infections respectively as followed: for S. mansoni 1–99 epg, 100–399 epg, ≥400 epg; A. lumbricoides, 1–4,999 epg, 5,000–49,999 epg and ≥50,000 epg; and for T. trichiura, 1–999 epg, 1,000–9,999 epg and ≥10,000 epg Fecal samples were collected and taken to the laboratory of Parasitology of the University of Kinshasa for analysis using the Kato-Katz technique Urine samples were analysed using the centrifugation method as described by Okanla Hemoglobin (Hb) levels were determined using a HemoControl device . Anemia was defined by a hemoglobin concentration <11, <11.5 and <12 g/dL, respectively for schoolchildren of less than 5 years, 5–11.9 years and 12–14.9 years old. Anemia was classified as severe anaemia Hb <7 g/dl, moderate anaemia Hb: 7–9.9 g/dl and mild anaemia Hb: 10–11.4 g/dl. Weight and height were measured in each child. With these measurements we calculate the following indicators using the WHO Anthroplus software: a) height-for-age Z-score (HAZ) to assess stunting in children 6 to 240 months old; b) weight-for-age Z-score (WAZ) to assess underweight in children of 6 to 120 months of age; and c) BMI-for-age Z-score (BAZ) to assess thinness in children of 6 to 60 months of age The sample size was estimated on the basis of the expected additional impact on anemia of the intervention arm versus the comparator The investigators agreed to conduct the present study in full agreement with the principles of the Declaration of Helsinki’ and subsequent relevant amendments. The study was approved by the Ethical Committees of the University of Antwerp, Belgium and of the School of Public Health, University of Kinshasa, DRCongo. Approval was also obtained from the Ministry of Health of DRCongo. Prior to the start of the project, special permission was obtained from the DRCongo Ministry of Education and the local health and education authorities of Biyela. A series of meetings were also held in the participating schools to explain the nature and purpose of the trial. Written informed consent (IC) was obtained from each parents or legal guardians of all children prior enrolment. An oral assent was obtained, as well, from children who were 12-years-old or older. All participants were administered albendazole  and praziquantel (40 mg/kg) against helminth infections. Children suffering from clinical malaria were treated according to national policy.95%:27.4–34.9), abdominal pain , diarrhea (15.3% CI95% 12.6– 18.4), and bloody feces (11.2% CI95% 8.9–14.0). Eleven percent of the children reported a history of blood transfusion . Two hundred seventy seven school children  were using the river as source of water to bathe or to wash their clothes.In total, 989 children aged between 4 and 13 years (median: 8 years and IQR:7.5–9.5 years) were assessed for eligibility in November 2012 of which 616 (62.3%) met the inclusion criteria and whose parents consented. A high frequency of refusal was found 324 (32.8%), with no real differences between schools in terms of percentage of parents refusing . Childre95%: 2.4–4.8) children presented fever with a mean temperature of 38.6 (SD 1.2). Blood smear, hemoglobin concentration and stool examination were performed, before they were treated according to the national policy. The prevalence of malaria parasitaemia amongst febrile children was 41.2% (CI95%:24.7–59.3). The median malaria parasite density was 9840/µL (CI95%:4660–14480). No S. mansoni infection was diagnosed in symptomatic children (95% :29.8–64.9)  .Plasmodium spp. infection was 18.5% (CI95%:15.6–21.9) and was found to be significantly lower than in symptomatic children. P. falciparum was the most prevalent species . P.malariae was diagnosed in two children. In those with parasitemia, the median parasite density was 1478/µl (IQR:557–5279) and was also significantly lower than 9840 parasites/µL found in symptomatic children (p = 0.01) , and girls  were less likely to have malaria infection. History of fever was an independent risk factor for malaria infection   .  . Schoolc = 0.03) . No signS. mansoni infection was 6.4% (CI95%:4.4–9.1) and the median parasite density was 48 eggs/g (IQR:24–76) and in girls . Other factors such as history of abdominal pain, diarrhea, bloody feces before enrolment did not demonstrate any association with S. mansoni infection . The liknfection .95%:28.6–37.4). Only two of the three majorSTH were found: Trichuris trichiura (26.3%) and Ascaris lumbricoides (20.1%). Hookworms were not found. However one case of a non-STH, Enterobius vermicularis was diagnosed. Girls  and younger children  had a significant lower risk for STH infection  and 6.4% (CI95% 4.4–9.1)  was found in 79 participants .Co-infection with malaria and a helminth was common though we did not observe any 4.4–9.1) . There wThe nutritional status of most children was within healthy parameters but a few cases of stunting (HAZ<−2) 0.16%, thinness (BAZ<−2) 0.65% and underweight (WAZ<2) 0.97% were observed .S.mansoni, and a 0.66 g/dl Hb lower when co-infected with STH (p = 0.02) than all not co-infected (The mean hemoglobin concentration was 11.6 g/dL (SD±1.4) and was found to be lower in children with asymptomatic malaria infection compared to uninfected children (p<0.001) . Hb concinfected . Other f95%:37.7–45.6) with no difference between sexes (p = 0.6). It was more common in P.falciparum-infected children (71.0%) than in uninfected children (38.8%) (p<0.001) . The multivariate regression model shows that anemia was associated with asymptomatic malaria infection  and S. mansoni infection  independently  . Of thesp<0.001) . In thisp<0.001) . No signendently . No inteP. falciparum in endemic areas is supposed to decrease significantly with age, because children would gradually developed some degree of immunity against the malaria parasite, as a result of repeated infections P. falciparum infection in endemic areas.In the Mokali Health Area, a semi-rural area of Kinshasa located in the Health Zone of Kimbanseke, the prevalence of asymptomatic malaria infection in schoolchildren was found to be 18.5%. Similar observations were made in 1981–1983 in Kinshasa, and 2000 in Kimbanseke T. trichiura having the highest prevalence, followed by A. lumbricoïdes (20.1%). These values are significantly lower than 90% and 83.3% respectively for A. lumbricoïdes and T. trichiura reported by Vandepitte in 1960 in Kinshasa A. lumbricoides infection, however improved sanitary, access to adequate water supply and access to health care should further decrease the prevalence of STH infections.Like malaria, STH were highly prevalent in the study population (32.8%). This could be the result of poor sanitary conditions in the Health Area of Mokali. This study recorded a prevalence of 26.2% for S. mansoni infection to be 6.4%. This prevalence is significantly lower compared to 89.3% reported in 2012 in Kasansa Health Zone, another endemic setting for S. mansoni in DRC S. mansoni infection. Similar observation was found in Yemeni in California This study also estimated the prevalence of P. falciparum and S. mansoni occurred at very low levels (1.5%). This is consistent with findings from Kenya in 2008–09 and Ethiopia 2008–09 and Uganda 2006 P. falciparum and STH co-infections were more frequent (6.4%). No association was found between malaria infection and S. mansoni infection neither between malaria infection and STH infection. This is in total agreement with previously reported data from Tanzania in 2010 Co-infection with S. mansoni infection was also found to be an independent risk factor for anemia in schoolchildren. No interaction was found between asymptomatic malaria infection and S. mansoni in regard to anaemia.On the other hand, the prevalence of anemia in primary schoolchildren was found to be 41.6%. This was lower than 67% observed in Kasansa, DRC in 2012 plasmodium spp carriage. Finally, no hookworms were found in Mokali’s schoolchildren. This could be at least partly explained by the fact that, the Kato-Katz slides were examined after 24 hours, which situation may lead to overclearance of hookworm eggs by glycerol.The study has a number of limitations. First, given the high rate of refusal (32.8%), which may lead to a selection bias, the reported data may not be representative of the schools surveyed. However, given that children whose parents did not consent were similar to those included in regard to age, sex and class, we have no reason to suspect that children in these two groups differed greatly in regard to other characteristics not assessed. This high proportion of refusal may indirectly suggest a negative perception of IPT or other malaria intervention in schoolchildren by the community. This underlines the urgent need to assess the perception and potential social and cultural barriers that can prevent an efficient implementation of malaria control strategies in schoolchildren. Second, asymptomatic malaria infection is mostly characterized by low grade parasitemia P. falciparum infection was highly prevalent in schoolchildren of Biyela Health Zone, and along with S. mansoni infection, they contribute to a great extent to the occurrence of anemia. These results highlight the important role of school-based interventions, which may include: deworming, micronutrients and intermittent preventive treatment for malaria for the control of anemia among African schoolchildren.This study demonstrated that