BnaGLN1 coding sequences and expression profiles in response to nitrogen availability and ageing are essentially conserved compared with A. thaliana, suggesting that the roles of GLN1 families are conserved among the Brassiceae tribe. BnaGLN1 genes coding for cytosolic glutamine synthetase isoforms (EC 6.3.1.2.) were found in the Brassica napus genome. The total number of BnaGLN1 genes, their phylogenetic relationships, and genetic locations are in agreement with the evolutionary history of Brassica species. Two BnaGLN1.1, two BnaGLN1.2, six BnaGLN1.3, four BnaGLN1.4, and two BnaGLN1.5 genes were found and named according to the standardized nomenclature for the Brassica genus. Gene expression showed conserved responses to nitrogen availability and leaf senescence among the Brassiceae tribe. The BnaGLN1.1 and BnaGLN1.4 families are overexpressed during leaf senescence and in response to nitrogen limitation. The BnaGLN1.2 family is up-regulated under high nitrogen regimes. The members of the BnaGLN1.3 family are not affected by nitrogen availability and are more expressed in stems than in leaves. Expression of the two BnaGLN1.5 genes is almost undetectable in vegetative tissues. Regulations arising from plant interactions with their environment (such as nitrogen resources), final architecture, and therefore sink–source relations in planta, seem to be globally conserved between Arabidopsis and B. napus. Similarities of the coding sequence (CDS) and protein sequences, expression profiles, response to nitrogen availability, and ageing suggest that the roles of the different GLN1 families have been conserved among the Brassiceae tribe. These findings are encouraging the transfer of knowledge from the Arabidopsis model plant to the B. napus crop plant. They are of special interest when considering the role of glutamine synthetase in crop yield and grain quality in maize and wheat.A total of 16  Brassica napus L.) is the dominant oilseed crop in northern Europe, and nitrogen (N) fertilization is the main operational cost for farmers . When compared with other crops, oilseed rape is characterized by low nitrogen use efficiency (NUE)  is a key enzyme which catalyses an ATP-dependent conversion of glutamate to glutamine using ammonium derived from primary N uptake and various internal N recycling pathways including catabolic release of ammonium during senescence . In a laGln1.4 is up-regulated during senescence  and functional genomics approaches mainly performed on maize  libraries  arising from the natural hybridization of monogenomic diploids Brassica rapa (AA) and Brassica oleracea (CC)  , containBnaGLN1 genes coding for GS1 isoenzymes. It is demonstrated that they are differentially regulated depending on tissue type, senescence, and N availability. The potential role of the BnaGLN1 genes in N remobilization during leaf senescence, the impact of whole-genome duplications and merging on the evolution of the GLN1 multigenic family in the Brassiceae tribe, and strategies based on knowledge transfer from A. thaliana to crop plants are discussed.In the present study, advantage is taken of the Brassicaceae genome structure and of its recent sequencing (unpublished) in order to identify all A. thaliana AtGLN1 coding sequences were performed in the GenBank and Genoplante databases using the BLAST algorithm , AtGLN1.2 , AtGLN1.3 , AtGLN1.4 , and AtGLN1.5 . The BlastN option was used to recover B. napus, B. rapa, and B. oleracea ESTs and complete mRNAs as well as genomic sequences of B. napus and B. rapa (http://brassicadb.org/brad/). Contigs of ESTs were built using the CAP3 algorithm . ESTs included in each contig are listed in Supplementary Data File 1 available at JXB online.Sequence searches by similarity to lgorithm  and the lgorithm  and valiBnaGLN1 contigs were then enriched and/or their coding sequence completed with new cDNA sequences: clones from Genoplante oilseed rape cDNA libraries and the ADIZ-MPIZ 021 library corresponding to ESTs were sequenced when available (Supplementary Table S1 at JXB online). When the coding sequence from cDNAs was incomplete or no clone was available, specific primers were designed to clone the total or missing coding region (Supplementary Table S2). The amplified fragments were cloned into pGEM®-T Easy plasmids (Promega) according to the recommendation of the supplier, and sequenced. Universal T6 and SP7 primers, as well as specific primers were used to sequence the clones on the positive and negative strands (Supplementary Table S3). All DNA sequencing was performed by Cogenics  and sequences were submitted to GenBank (accession numbers are given in Supplementary Table S1).http://mobyle.pasteur.fr). The NCBI Conserved Domain Database  populations. The Stellar×Drakkar (SD), Darmor×Samouraï (DS), and Darmor-bzh×Yudal (DY) populations consist, respectively, of 94, 134, and 445 genotype DH lines described by Supplementary Table S2 at JXB online). Linkage analyses were performed as previously described by BnaGLN1 genes were assigned to a linkage group using the ASSIGN command (LOD threshold=8.0) and then placed in the most confident interval with the PLACE command (LOD threshold=2.0). Recombination frequencies were converted into centiMorgans (cM) with the Kosambi function .BnaC.GLN1 genes was realized using monosomic and polysomic addition lines carrying one or several additional C chromosomes from Darmor-bzh. Lines were selected from a cross between B. napus Darmor-bzh and B. oleracea C1.3 . Genomic DNA from these lines was PCR screened with specific but not polymorphic markers (Supplementary Table S2 at JXB online).Chromosome assignment for Brassica napus L. plants from the Darmor-bzh genotype were grown in a greenhouse at INRA Versailles, France. Seeds were sown on sand and watered with nutritive solution during 2 weeks in order to allow germination and subsequent growth of plantlets. When the first two true leaves appeared, plantlets were transferred into pots containing sand and were separated into two groups with contrasting N fertilization regimes  according to Brassica napus L. plants from the Express genotype were grown in field trials in 2009–2010, in Le Rheu (Brittany), France. Seeds were sown on 7 September 2009 with plant density set at 40 plants m–2. The field trial was conducted with contrasting N fertilization regimes. Plant N status was monitored over the vegetative stage by calculating the nitrogen nutrition index (NNI) . LN and HN plants were harvested, respectively, on 9 and 12 April, at the beginning of the flowering period when half the plants of the plot had their first flowers open on the main stem , and 400 degree-days later (base 0) on 17 and 20 May at the beginning of the seed filling period .2 per plot (~20 plants) were harvested in the early morning and sampled during the subsequent hour. For each batch, plants were ranked according to their length and developmental stage; the six median plants were selected for sampling. On the main stem, the lowest leaf starting to yellow (Old) and the highest leaf at least 5cm long (Young) were selected, the petiole and main vein were removed, and limbs were sampled. The stems above young and old leaf insertions were selected and sampled over 2cm and 4cm, respectively. All fresh samples were frozen immediately in liquid nitrogen and stored at –80 °C.Plants from 0.5 mTaq DNA polymerase (Promega) in the appropriate buffer supplemented with 2.5mM MgCl2. The amplification program was run on a PTC-225 thermocycler  with the following conditions: 35 cycles of denaturation at 94 °C for 30 s (3min for the first cycle), annealing at 55–60 °C for 30 s, and elongation at 72 °C for 1–2min (10min for the last cycle).PCRs were conducted in a 20 μl mix containing 2–10ng of DNA, 0.25mM dNTPs (Promega), 0.5 μM of each primer , and 0.5U of 12–18 primers and Superscript III reverse transcriptase (Invitrogen) according to the manufacturer’s instructions. Two independent reverse transcription reactions were performed as technical replicates. cDNA samples were diluted 26-fold with sterile water before use.Total RNAs were extracted with the SV Total RNA Isolation System (Promega) from 70mg fresh weight (FW) of ground frozen tissue. First, samples were homogenized in the RNA lysis buffer (400 μl) using TissueLyserII from Qiagen. Then, all cell debris was eliminated by filtering the lysate through a ‘Nucleospin 96 RNA filter Plate’ (Macherey-Nagel). The manufacturer’s protocol was then followed. In order to remove any remaining DNA traces, 1.5 μg of RNA was treated with DNase using the Turbo DNA-free kit (Ambion) according to the manufacturer’s protocol. The quality of RNA was assessed by an electrophoresis on agarose gel , and the absence of DNA contamination in samples was confirmed by PCR amplification. First-strand cDNA was synthesized using 2 μg of total RNA with oligo(dT)Quantitative PCRs (qPCRs) were set up with the LightCycler 480 SYBR Green I Master mix (Roche Diagnostics) and 4 μl of diluted cDNA in a final volume of 12 μl. The concentration of specific forward and reverse primers was set at 0.42 μM. qPCRs were run on a Light Cycler LC480 (Roche Diagnostics) under the following conditions: an initial step at 95 °C for 10min, then 50 cycles of 95 °C for 10 s, 60 °C for 10 s, and 72 °C for 20 s.BnaGLN1 family and five reference genes (Supplementary Table S4 at JXB online). Identification of B. napus reference genes for reverse transcription–qPCR analysis was based on EST sequence similarity to A. thaliana genes with verified expression stability over a wide range of tissues and growing conditions. Arabidopsis thaliana genes were selected from among the list established by B. napus ESTs from GenBank using the BlastN algorithm. One B. napus EST per reference gene was selected to design qPCR primers (Supplementary Table S4).Primer pairs were designed for short and specific amplification of individual members of the multigenic For each run, single product amplification was confirmed by melt curve analysis. PCR products from each primer pair and genotype were sequenced in a preliminary analysis. The amplification efficiency was assessed for each genotype, with each primer pair using a dilution curve method over six orders of magnitude, on a pool of cDNAs from different tissues and modalities. Selected primer pairs have efficiencies >1.8.The results reported were obtained from four biological replicates and two reverse transcriptions as technical replicates. All samples, including reverse transcription and biological replicates, were run at the same time for each primer pair. Raw fluorescence data were collected and analysed with the R package ‘qpcR’ . The ‘pcBnaX.PTB, BnaX.SAND, BnaX.PP2A, and BnaX.UBC21 from the five tested were retained with an average M value equal to 0.33. For each cDNA sample, a normalization factor (NF) was calculated as the geometrical mean of RQ from the four selected genes, and normalized RQ (NRQ) was then calculated as NRQ=RQ/NF. The mean of both technical replicates was then calculated for each sample.The most stable reference genes were selected using the GeNorm method from B. napus ESTs, 126 B. rapa ESTs, and 36 B. oleracea ESTs highly similar to one or several of the five AtGLN1.1–AtGLN1.5 mRNA-coding sequences from A. thaliana were isolated from public and private Genoplante databases (Supplementary Data File S1 at JXB online). Sequence assembly and alignments with AtGLN1 mRNA sequences revealed different groups of transcripts that allowed ESTs to be grouped and 16 individual contigs that might correspond to different BnaGLN1 genes of B. napus to be extracted (Supplementary Data File S2). Eight contigs for B. rapa and seven contigs for B. oleracea were also isolated . The BnaGLN1, BraGLN1, and BolGLN1 contigs from B. napus, B. rapa, and B. oleracea, respectively, show high levels of sequence similarity with all the five AtGLN1 genes  and dicotyledonous species. The Brassicaceae sequences are divided into five clusters, each one including one A. thaliana and one or several B. napus, B. oleracea, and B. rapa sequences  gene with the highest sequence similarity. Since for each AtGLN1.x sequence several BnaGLN1 sequences were found, contig names were also extended by a copy number (Cn): BnaGLN1.x_Cn . For the few EST assemblies that cannot be confirmed in this way, the cloning of missing coding sequences (CDS) was performed by designing primers from the B. rapa and B. oleracea homologous contig sequences . This allowed the completion of the BnaGLN1.4_C3 and BnaGLN1.4_C4 sequences.Most of the EST assemblies have been confirmed through sequencing partial or full-length cDNA clones when available .Except for the four BnaGLN1.1_C1, BnaGLN1.1_C2, BnaGLN1.2_C1, and BnaGLN1.2_C2 contigs, no other BnaGLN1 gene and a gene from one or other of the progenitors B. rapa and B. oleracea, suggesting a common ancestral origin on the A or C Brassica genome, respectively. The phylogenetic tree also shows that each B. napus sequence, related to one sequence from either progenitor, is also related to another B. napus sequence, itself related to the other progenitor. The two B. napus homeologous genes, the B. rapa and the B. oleracea genes, are thus defining in this way a homeology group . It was found therefore that each of the AtGLN1.1, AtGLN1.2, and AtGLN1.5 genes is related to one homeology group, while the AtGLN1.3 and AtGLN1.4 genes are related to three and two groups, respectively. It has to be noted that the b group related to AtGLN1.3 is incomplete as no BolGLN1.3 expressed sequence has been identified. Both the homeology groups and the Brassica genome were used to ascribe names to the BnaGLN1 genes; thus, the genes are named Bna[A or C genome]GLN1.x according to BraGLN1 and BolGLN1 genes . Five genes were mapped in this way on at least one of the three mapping populations available , recording the presence/absence of polymorphism. In good agreement with the phylogenetic tree analysis, the three genes BnaA.GLN1.3.c, BnaA.GLN1.3.a, and BnaA.GLN1.5.a were localized on linkage groups associated with the A genome on chromosomes A03, A05, and A06, respectively. The two genes BnaC.GLN1.2.a and BnaC.GLN1.3.c were localized on linkage groups associated with the C genome on chromosomes C02 and C03 .In order to identify the A or C genome origin, the potential localization of the BnaGLN1 gene family, an attempt to assign the BnaGLN1 genes to the A or C genomes using mapping populations was unsuccessful. Therefore, a panel of various Brassicaceae genotypes  was used in order to detect the BolGLN1 and BraGLN1 orthologous genes, using specific BnaGLN1 primers (Supplementary Table S1). The number of genotypes used for each Brassica species was adjusted in order to take into account the possible allelic variations and to detect the presence/absence of polymorphism. Furthermore, additional lines carrying the full A genome and one or several B. napus C chromosomes were used in order to determine preciselg the localization of the BnaC.GLN1 genes .For the other members of the Supplementary Figs S1, S2, and S3 at JXB online. In brief, with the exception of BnaC.GLN1.4.b, all the identified BnaGLN1 genes were assigned to the A or C Brassica genome, confirming the two by two relationship of homology between them, which allowed them to be named according to their ancestral genome origin as recommended by The results are summarized in B. rapa genome . According to the BRAD annotation, this inserted region has been described as an long terminal repeat (LTR) transposon of 3746bp on the minus strand. The identified B. rapa EST (EX089134) that allowed identification of the 5′ region of the BraGLN1.3_C2 contig starts in the transposon region and continues into the first identified exon of Bra001686 which corresponds to the second AtGLN1.3 exon.The recently sequenced and annotated N1 genes . AlignmeBnaGLN1 sequences in the B. napus Darmor-bzh genome . The BraGLN1 protein sequences were deduced from the identified BraGLN1 genes using the BRAD tool, and used to search the database of protein sequences built from B. napus genomic sequence analysis (unpublished data). From the BnaGLN1 protein sequences identified, genomic sequences were recovered (Supplementary Data File S4 at JXB online). Interestingly, 16 putative BnaGLN1 genes and two putative BnaGSL genes (coding for the GS2 isoform) were found. The 16 BnaGLN1 genomic sequences (Supplementary Data File S4) were used to analyse similarities with the B. napus contigs and to create a phylogenetic tree . Interestingly, each genomic sequence was closely associated with one contig sequence, suggesting that all the genes with the 16 BnaGLN1 contigs had been found. The deduced mRNA sequences (Supplementary Data File S5), obtained using FGENESH software available on the SoftBerry website (http://linux1.softberry.com/berry.phtml?topic=fgenesh&group =programs&subgroup=gfind), showed very a high similarity with the contig sequences (B. napus genotypes (Supplementary Data File S1), this indicates that there is almost no polymorphism between the different BnaGLN1 coding sequences regarding the various genotypes of B. napus used for genome and EST sequencing. The BnaGLN1 genes contained between seven and 12 exons. GLN1.4 and GLN1.5 genes have the same number of exons in both B. napus and Arabidopsis  were identified . The resBnaGLN1 genes are probably differentially expressed according to tissue and developmental stage (Supplementary Data File S1 at JXB online).A first analysis of EST distribution between libraries and BnaGLN1 contigs led to the conclusion that BnaGLN1 gene expression was monitored at the vegetative stage measuring transcript levels by quantitative real-time RT–PCR in samples of taproot, crown, limbs, and veins of plants grown under low or high nitrate conditions. Plants grown under low or high nitrate conditions grew 13 and 17 leaves, respectively. Fv/Fm and SPAD measurements on all the leaf ranks (numbered from the bottom leaf to the top leaf) were done to estimate the relative leaf senescence status of each leaf. From both SPAD and Fv/Fm as senescence markers, six leaves were selected from each nitrate condition presenting differential senescence levels to perform further experiments . Induction under low nitrate conditions was also clearly observed in the taproot and crown . Cumulated expression of the BnaA.GLN1.5.a/BnaC.GLN1.5.a genes  and the two corresponding stem sections  were collected at flowering and during grain filling.In order to monitor BnaGLN1 expression were similar to those found at the vegetative stage, except that the magnitude of gene repression or induction was lower than that observed at the vegetative stage (Supplementary Table S5 at JXB online).Globally, effects of N limitation on BnaGLN1 genes in leaves and stems of plants grown under a sufficient N regime. As a control of leaf senescence stages, the BnaGSL1 and BnaGSL2 genes are significantly more highly expressed in the young tissues than in older tissues . As observed with the BnaGLN1.1 genes, the effect of senescence was no more significant at seed filling.As observed at the vegetative stage, the ng stage , B. Duriin stems , D. The BnaGLN1.4 genes, only BnaA.GLN1.4.a and BnaC.GLN1.4.a shared similar expression profiles  in CDS, which is less than the preliminary observation showing sequence divergences of ~3–5% SNPs in CDS from SLR1 . This suggests that coding but also regulatory sequences were essentially conserved after genome merging of B. napus progenitors, but also after the whole-genome duplication (WGD) and diploidization events that occurred in the Brassica lineage after the divergence from the Arabidopsis genus. WGD is generally thought to provide raw material for gene neo- and subfunctionalization, extending resilience to deleterious mutations, increasing the net speciation rate and species richness , BnaGLN1.3.a , and BnaGLN1.4.a homeologues, and in favour of the B. rapa parental genome for BnaGLN1.1.a and BnaGLN1.2.a. These results are in agreement with the recent finding that nearly 7% of the potentially identified homeologous genes expressed in a leaf extract are displaying a differential expression level in favour of the A or C parental genome for 1/3 and 2/3 of the pairs, respectively, and that genes involved in metabolic processees tend to be over-represented  are also more highly expressed in roots than in shoots , final architecture, and therefore sink–source relations in planta, seem to be globally conserved when compared with data available from the Arabidopsis model. Considering the architectural, size, and lifespan differences between A. thaliana and B. napus, it is not surprising to find some differences in gene expression profiles. Also, due to the higher number of GLN1 genes conserved in the B. napus genome, it seems correct to find some specificities in the expression of each BnaGLN1 in contrast to genes involved in flavonoid biosynthesis that display highly conserved expression profiles between A. thaliana and B. napus during seed development and are highly dependent on tissue differentiation (BnaGLN1 gene expression would refine the hypothesis concerning their physiological role. Indeed, the present expression study relied on leaf blade and stem samples consisting of different tissues with contrasting physiological roles, in particular parenchyma and vascular tissues. Such a localization study could be advantageously performed in Arabidopsis and B. napus to provide a new basis for comparison of the evolution of this gene family.A total of 16 JXB onlineSupplementary data are available at Figure S1.BnaGLN1 gene localization on the A or C genome using a panel of various Brassica genotypes.Figure S2.BnaGLN1 gene localization on LGs using mono- and polysomic additional lines.Figure S3. Positions of BnaGLN1 genes on the B. napus genetic map.Figure S4. Alignments of the genomic sequence, deduced mRNA sequence, and contig of EST sequences are reported for each BnaGLN1 gene.Figure S5. Expression of BnaGLN1 genes is modified depending on nitrate availability and ageing in primary veins of vegetative B. napus plants.Table S1. Clones from Genoplante and ADIS-MPIZ oilseed rape cDNA libraries used for BnaGLN1 mRNA sequencing.Table S2. Primers used for cloning and genetic mapping of the BnaGLN1 gene.Table S3. Specific primers used for sequencing BnaGLN1 cDNAs.Table S4. qPCR primers used for BnaGLN1 gene expression analysis.Table S5. Induction of BnaGLN1 gene expression under low N fertilization in field-grown plants.Data File S1. List and description of EST sequences belonging to each B. napus, B. oleracea. and B. rapa GLN1 contig, and tables of the distribution of ESTs between libraries according to their BnaGLN1 contigs.Data File S2. BnaGLN1 contig sequences in fasta format.Data File S3. Global multiple alignment of nucleotide sequences in the study.Data File S4. Genomic sequences of the BnaGLN1 genes.Data File S5. Deduced BnaGLN1 mRNA sequences.


Brazilian jiu-jitsu (BJJ) is a dynamic martial art that can potentially tax both the anaerobic and aerobic metabolic systems of the body. Although BJJ has been practiced for decades in Brazil, it has only been practiced in the United States for ~ 20 years and has steadily increased in popularity since that time. There is a lack of research describing the physiological profiles and nutritional habits of advanced BJJ practitioners.Apparently healthy, males between the ages of 18-44, who are currently training in Brazilian jiu-jitsu were recruited and volunteered to participate in this ongoing study. Along with assessing various measures of physical fitness, 24-hour dietary records were obtained to assess basic nutritional parameters including eating occasions and recent dietary supplement usage in advanced (purple belt or higher) Brazilian jiu-jitsu practitioners. Consent to publish the results was obtained from all participants.Results are presented as means + standard deviations. The average age of the subjects was 31 ± 7.3 years. The average height was 175.7 ± 7.2 cm, average weight was 78.7 ± 7.9 kg, and body fat percentage was 9.5 ± 1.9%. The average duration of BJJ experience was 8.4 ± 4.6 years. Based on the self-reported dietary record, the frequency of eating occasions was 4.8 ± 0.4 occasions per day. 80% of the participants reported consuming some form of dietary supplement in the previous 24 hours. Dietary supplements consumed included vitamin supplements, protein shakes, meal replacement products, and pre-workout energy drinks.This limited preliminary data provides insight into basic patterns of eating frequency and dietary supplement use in advanced Brazilian jiu-jitsu practitioners. However, more research is needed to make more conclusive statements regarding the profiles of this demographic.


Low back pain (LBP) is a common health problem with concomitant disability which has assumed a public health importance in our setting.The aim of this study was to determine the prevalence of LBP and associated risk factors amongst adult patients attending the General Outpatients’ Clinic of the University College Hospital in Ibadan, Nigeria.This was a cross-sectional study of 485 respondents. A semi-structured questionnaire was used to obtain information on socio-demography, lifestyle, occupation and other risk factors associated with LBP.There were 288 (59.4%) female and 197 (40.6%) male respondents. The point prevalence of LBP was 46.8%. Occupational activities, previous back injury and tobacco smoking were significant associated factors for the total population. For the female respondents, logistic regression analysis showed that a waist circumference of 88 cm or more, dysmenorrhea, previous back injury and being engaged in an occupation were the most significant factors associated with LBP. However, previous back injury was the most significant factor associated with LBP for the male respondents.The prevalence of LBP amongst adult patients in our setting is high, with preventable and treatable predisposing factors. Public health efforts should be directed at educating people on occupational activities and lifestyle habits. Chronic LBP is one of the four disabilities causing musculoskeletal conditions – the others being osteoarthritis, osteoporosis and rheumatoid arthritis.5 The economic burden of LBP on the society, especially in low-resourced continents like Africa, is enormous and continues to increase. Billions of dollars spent annually on managing LBP further constrains the fragile health care system in Africa, which is already ravaged by the HIV epidemic.5Musculoskeletal problems are prevalent amongst the adult population.6 Chronic LBP is the most common musculoskeletal problem encountered in the workplace, with attendant loss of quality of life and financial difficulty.7 Chronic LBP is prevalent in many industrialised societies with prevalence rates of 21% and 39% being reported in the general population - and even higher in the occupational setting.8 In the USA, LBP is the commonest musculoskeletal illness with 12% – 30% of the population affected at any given time.9About 40% of sick absences from work is because of LBP - making it the second most common cause of workplace absenteeism after the common cold.9 More than 80% of the population will experience an episode of LBP at some time during their lives.10 The clinical course is benign for most, with 95% of those afflicted recovering within a few months of onset. Some, however, will not recover and will develop chronic LBP, i.e. pain that lasts for three months or longer.10Occupation-related factors are the most important risks associated with LBP.11 Other mutable factors are occupation-related: poor posturing, prolonged sitting, twisting, bending, stooping and lifting of heavy loads.11Risk factors for developing LBP could be immutable (non-modifiable) or mutable (modifiable). The immutable factors are age, parity, previous history of LBP and major scoliosis, whilst the mutable factors include a sedentary lifestyle, obesity, tobacco smoking and drug dependence.7 This may be due to fact that LBP is perceived to be of little public health importance when compared with other medical conditions such as hypertension and diabetes mellitus.7 This study was carried out to determine the point prevalence and risk factors of LBP amongst adult patients presenting to a family practice clinic in Nigeria.There is scanty information available on LBP in resource-constrained countries like Nigeria.The head of the Family Medicine department  approved this study. Respondents gave their informed consent before the administration of their questionnaire and physical examination.12 Most patients coming to UCH are seen first at the GOP Clinic, which functions as a secondary care clinic within a tertiary hospital setting. Patients are at first contact seen by consultants and resident doctors in family medicine.The study was conducted at the General Outpatients’ (GOP) Clinic of the Family Medicine Department of the University College Hospital (UCH) in Ibadan, Nigeria. UCH is a tertiary institution founded in 1957 in the cosmopolitan city of Ibadan. Ibadan is the capital of the Oyo state in south-western Nigeria and has a population of 3.6 million people, mainly of the Yoruba tribe.This was a cross-sectional study.The population consisted of 485 patients who presented to the GOP Clinic (UCH) between 15 January 2011 and 30 March 2011. The inclusion criteria were all patients aged 18 years and above who consented to take part in the study. Those who did not consent to the study, who had congenital deformity of the spine or who were too ill to participate in the study were excluded.All adult patients who met the study criteria were consecutively selected.A semi-structured questionnaire was used to interview the respondents. The questionnaire was pretested to determine if the questions were clear and comprehensive enough to address the set objectives of the study and necessary amendments were then made. Information obtained from the respondents included their socio-demographic characteristics and lifestyle habits. Additionally, their health care utilisation pattern was obtained by asking them about the number of times they had been hospitalised for LBP, the total period spent on admission, the frequency of outpatient hospital visits in the last year and the treatment they sought for their LBP. Anthropometric measurements of height, weight, waist and hip circumferences were carried out for all respondents.2, ‘Normal’ to a BMI of 18.5 kg/m2 – 24.9 kg/m2, ‘Overweight’ to a BMI of 25.0 kg/m2 – 29.9 kg/m2 and ‘Obese’ to a BMI greater than 30.0 kg/m2. To identify individuals with possible health risks, the waist circumference of the respondents was measured and this was based on the threshold values of ≥ 88 cm for women and ≥ 102 cm for men.14 The waist/hip ratio (WHR) was calculated by dividing the waist circumference by the hip circumference.14 The cut-off point of WHR was defined as ≥ 0.85 for women and ≥ 1.00 for men.14 The questionnaire took an average of 22 min to be completed.The weight (in kilogram) was divided by the height (meter) and then squared to calculate the body mass index (BMI). The BMI was graded along the World Health Organization's (WHO) classification, where ‘Underweight’ refers to a BMI less than 18.5 kg/mHeight was recorded to the nearest 0.1 m with a measurement stand (stadiometre) that was positioned on a flat surface. The respondents were asked to remove their shoes and their heels were positioned against the wall, with their scapula, buttocks and heels resting against the wall. Female respondents were asked to remove their headwear. The weight of the respondents was measured to the nearest 0.1 kg using a standard weighing scale manufactured by Hana, China. Respondents stood on the weighing scale after removing their personal effects. The researcher made the readings whilst standing in front of the respondents and the zero mark was checked for accuracy after every reading. Waist and hip circumferences were measured to the nearest 0.1 m using a flexible non-elastic measuring tape.Respondents were treated for their primary health complaints and those needing further treatment were referred to other specialty clinics within the facility.® (version 16). Descriptive statistics was employed for the socio-demography, lifestyle and health care utilisation pattern of the respondents. Categorical and discrete variables were tested using the Chi-square statistics and continuous variables were tested using the t-test. The relationship between socio-demography, lifestyle, health care utilisation and LBP was explored using logistic regression analysis. The p-value of significance was set at ≤ 0.05.Administered questionnaires were checked, sorted and coded serially at the end of each study day. The data was entered, cleansed and analysed using SPSSThere were 288 (59.4%) female and 197 (40.6%) male respondents in the study population, with the female to male ratio being 1.5 to 1. The mean ± standard deviation (SD) of the respondents’ age was 42.5 ± 15.5 years (range: 18 to 85 years). Their monthly income ranged from 2000 to 400 000 Naira ($13.33 to $2666.67) with a median income of 18 500 Naira ($123.33). The modal age group was less than 30 years and only 70 respondents (14.4%) were elderly. The majority of the respondents were married and 306 (63.1%) were literate, having completed the first 10 years of formal education (i.e. attained senior secondary and tertiary education). There were 331 respondents (68.2%) living with their immediate family (spouse and children or grandchildren) and 363 (74.8%) were currently engaged in occupational activities. The male respondents were mostly self-supporting whereas the females were mostly dependent on their spouses for financial support . The sel2 = 1.586, p = 0.208). The prevalence of LBP increased gradually with age: from 44.9% for respondents younger than 30 years to 55.6% for the age group 51 years - 60 years. However, a reduction in the prevalence of LBP was observed after the age of 60 . A higher prevalence of LBP was found in respondents who only had primary school education (55.7%), lived alone (50.6%), had more than five children (52.3%) and were self-supporting (49.6%), as shown in 2 = 5.421 and p = 0.020 .ge of 60 . There w = 0.020 . The maj2 = 2.174, p = 0.704). The prevalence of LBP was significantly higher amongst respondents who had previous back injury (91.3%) compared with those who did not (44.8%), where χ2 = 14.64 and p < 0.001. The lifestyle habits of the respondents showed that 71 respondents (14.6%) regularly consumed alcohol, 12 respondents (2.5%) smoked tobacco and 102 respondents (21.0%) engaged in regular physical exercise. The prevalence of LBP was significantly higher in respondents who smoked tobacco than those who did not (91.7% vs. 45.7%), where χ2 = 9.946 and p = 0.002. However, no association was found between the prevalence of LBP and alcohol consumption or physical exercise. Mattress or foam (94.8%) was the commonest sleeping material used by the respondents, with the majority (83.7%) using the soft type. The majority of respondents using either the firm type (55.4%) or the orthopedic type (70.0%) had LBP. However, there was no significant association between the sleeping material and LBP . Amongst the female respondents, the prevalence of LBP was significantly higher in those who had dysmenorrhea compared with those who did not (57.9% vs. 39.6%), where χ2 = 7.565 and p = 0.006 (The highest proportion of LBP (63.6%) was found amongst respondents who commonly adopted the stooping position during their daily activities, whilst the lowest proportion (48.5%) was found in those who commonly adopted the standing position . There w = 0.006 .2 ± 5.5 kg/m2 (16.2 kg/m2 – 51.9 kg/m2). The mean weight of male respondents (67.3 kg ± 1.3 kg) was more than those of the females (66.4 kg ± 1.4 kg) without a significant difference . The mean height of the male respondents was significantly higher than those of their female counterparts (1.67 m ± 0.09 m vs. 1.60 m ± 0.08 m), where t = 83.340 and p < 0.0001. Conversely, the mean BMI of the female respondents was significantly higher than those of their male counterparts (25.91 ± 5.52 vs. 24.16 ± 5.29), where t = 11.758 and p = 0.001. The mean waist circumference of the respondents was 79.2 cm ± 12.9 cm (50 cm – 128 cm) and the mean hip circumference was 87.2 cm ± 15.4 cm (43 cm – 133.1 cm). The mean waist/hip ratio (WHR) was 0.91 ± 0.07 (0.48 – 1.36). The mean waist and hip circumference of the female respondents was significantly higher than those of their male counterparts  respectively. However, the mean WHR of the females was significantly lower than those of the males (0.908 ± 0.07 vs. 0.923 ± 0.08), where t = 5.267 and p = 0.022 (Anthropometric measurements of the respondents showed that the mean weight of the respondents was 66.7 kg ± 13.8 kg (37 kg – 129 kg) and the mean height was 1.63 m± 0.09 m (range: 1.10 m –1.90 m). The mean body mass index (BMI) was 25.2 kg/m = 0.022 .2 = 0.739, p = 0.864). A higher proportion of men (70%) with a waist circumference of 102 cm or more reported LBP than those with a waist circumference less than 102 cm (49.2%). However, this difference was not statistically significant . Amongst the females, the prevalence of LBP was significantly higher in those with a waist circumference of 88 cm or more than in those whose waist circumference was less than 88 cm (61.8% vs. 38.2%), where χ2 = 12.656 and p < 0.001. Additionally, women with a WHR of 0.85 or more had a higher prevalence for LBP than those with a WHR less than 0.85 (44.8% vs. 42.6%), where χ2 = 0.081 and p = 0.775.Of the 227 respondents who had LBP, only a few (22.5%) reported experiencing their first episode of LBP. The average duration of the LBP was 24 months and 6 respondents (2.6%) had been admitted to hospital for LBP. The average duration of hospitalisation was 3 days. Sixty-three respondents (27.8%) with LBP reported visiting the hospital on an outpatient basis 2.1 ± 1.8 times in the last year. Of these 63 respondents, 26 (41.3%) visited the hospital on an outpatient basis once, 27 (42.9%) visited twice, 5 (7.9%) visited three times and 5 (7.9%) visited four or more times in the last year.p = 0.005, OR = 1.029, CI =1.009 – 1.050), dysmenorrhea , previous back injury  and being engaged in an occupation  were found to be most associated with LBP. Amongst the male respondents, previous back injury  was found to be most associated with LBP  than women (32%).16 Louw reported in a systematic review that the point prevalence of LBP amongst African adolescents and adults was 12% and 32% respectively.5 Similarly, Taechasubamorn et al. reported the highest prevalence of LBP amongst young adults aged 25 years to 34 years.15 Older people were found to experience the more persistent and severe form of LBP compared with young adults.17 A report from Sweden showed that LBP was common amongst elderly Post Office pensioners who had previously engaged in lifting heavy loads for more than 20 years.17Some authors reported that the risk of developing LBP increases with advancing age and amongst females, however, others studies reported no such association between these factors.18 Physical efforts, such as manual exertion and exposure to whole-body-vibration are the common physical ergonomics related to LBP.9 Some authors found that the majority of those reporting LBP were frequently exposed to ‘stressful situations’ in their occupation.11In this study, occupational activities and previous back injury were significantly associated with LBP. Thirty-seven percent of back pain worldwide accounts for an estimated 0.8 million disability-adjusted life years (DALY) with resultant work time and economic loss.8 In addition, most rice farmers experienced increased LBP from slouched sitting (56.2%), forward bending (70.8%) and lifting (83.2%).15The highest proportion of LBP in this study was found amongst respondents who commonly adopted the stooping position during their daily activities. This is comparable to the findings of another Nigerian study that associated LBP with heavy physical work, bending, poor posture and prolonged sitting or standing.p = 0.377). This result differed from the multicenter trial by Kovacs, where pain and disability amongst patients with chronic, non-specific LBP improved when using the medium firm mattresses.19 The firmness of the mattress was rated in their study along the European Committee for Standardization scale, with the firmest mattress rated as 1 and the softest rated as 10.19 Self-assessment of the mattress type was carried out by the respondents in this study, which could have affected the results.The majority (57.3%) of the respondents using either the firm or orthopedic mattresses had LBP. Our study found no significant association between LBP and the sleeping materials  was significantly associated with LBP. This is similar to the report in which 71% of the respondents were found to be either overweight or obese, with 16% not being physically active and 35.9% engaging in less than 30 minutes of exercise daily.11For the female respondents in this study, logistic regression analysis showed that a waist circumference of 88 cm or more  was associated with LBP. This is similar to the study in which LBP and headaches were found to contribute the most to the severity of dysmenorrhoea.22Being overweight is more common in women compared with men. Its prevalence increases in mid-life and then decreases over time. Being overweight causes an increase in the pressure on the structures of the lower back and that may lead to lumbar disc herniation and subsequent LBP. Studies reported an association between being overweight and experiencing LBP.23 In Australia, LBP is commonly treated with exercise.11 Lifestyle modification, such as regular exercise, smoking cessation and weight reduction, and culturally acceptable health promotion programmes have been found to be beneficial in reducing the disability associated with LBP.11 Workers at risk of LBP need to modify their postures during occupational activities by preventing excessive flexion and extension movements.2 In our setting there is a high prevalence of LBP amongst adult patients, with several modifiable risk factors identified. Various levels of prevention should be employed to alter occupational activities and lifestyle habits.Back pain is a common cause of absenteeism at work and functional disability, which has assumed a public health importance.


To evaluate the coverage and timeliness of the Expanded Programme on Immunisation (EPI) in The Gambia.Vaccination data were obtained between January 2005 and December 2012 from the Farafenni Health and Demographic Surveillance System (FHDSS), the Basse Health and Demographic Surveillance System (BHDSS), the Kiang West Demographic surveillance system (KWDSS), a cluster survey in the more urban Western Health Region (WR) and a cross sectional study in four clinics in the semi-urban Greater Banjul area of WR. Kaplan-Meier survival function was used to estimate the proportion vaccinated by age and to assess timeliness to vaccination.BCG vaccine uptake was over 95% in all regions. Coverage of DPT1 ranged from 93.2% in BHDSS to 99.8% in the WR. Coverage decreased with increasing number of DPT doses; DPT3 coverage ranged from 81.7% in BHDSS to 99.0% in WR. Measles vaccination coverage ranged from 83.3% in BHDSS to 97.0% in WR. DPT4 booster coverage was low and ranged from 43.9% in the WR to 82.8% in KWDSS. Across all regions, delaying on previous vaccinations increased the likelihood of being delayed for the subsequent vaccination.The Gambia health system achieves high vaccine coverage in the first year of life. However, there continues to be a delay to vaccination which may impact on the introduction of new vaccines. Examples of effectively functioning EPI programmes such as The Gambia one may well be important models for other low income countries struggling to achieve high routine vaccination coverage. As the 2015 target date for the Millennium Development Goals (MDGs) approaches, there is the need to evaluate health programmes and assess how effective they are. The Expanded Programme on Immunisation (EPI) has been one of the most successful global childhood programmes, reducing mortality and morbidity from vaccine-preventable diseases and providing opportunities for other interventions. EPI vaccination visits  are crucial contact points between a child and the health system, where vaccines and other essential health care interventions like Long-Lasting Insecticidal Nets (LLINs), de-worming, vitamin A, and growth assessments, are given Despite the EPI's impact on child health the burden of vaccine-preventable diseases, particularly in the most vulnerable infants, remains high Approval was obtained from Gambia Government/Medical Research Council Joint Ethics Committee.http://www.who.int/countries/gmb/en/). Data sources were obtained from four different geographical regions; Western health Region (WR), North Bank Region (NBR), Lower River Region (LRR) and Upper River Region (URR)  . The stuVaccination data were obtained from three rural demographic surveillance sites in The Gambia; the Farafenni Health and Demographic Surveillance System (FHDSS) In June 2010, vaccine coverage in the Western Health Region (WR) was assessed in 12–23 month olds using the cluster survey technique recommended by the World Health Organization Between January 2010 and December 2011, a cross sectional study was carried out in four clinics in the semi-urban Greater Banjul area of WR. All children aged 9 to 60 months attending the well-baby clinics at the Fajikunda, Sukuta, and Serrekunda health centres and Jammeh Foundation for Peace Hospital (JFPH), and who had not been involved in previous vaccine trials were invited to participate. A questionnaire on vaccination status and socio-demographic characteristics was administered to the caregivers.Vaccine coverage for the primary series  and measles vaccines) and the booster dose of DPT administered at 18 months were calculated. A child was considered to have been vaccinated if a vaccination date was recorded and not vaccinated if no vaccination date was recorded. The proportion vaccinated was calculated for BCG and measles vaccines and by the number of DPT vaccine doses as the number of vaccinated children divided by the total number of surveyed children eligible for vaccination at time of interview according to the vaccination schedule . A DPT bYearly birth cohorts were used  so that denominators and numerators were of the same group and to take account of delayed vaccinations that went across calendar years. For each vaccine, the proportion vaccinated by age was estimated using 1 minus the Kaplan-Meier survival function http://www.stata.com).To assess timeliness of vaccination we used the current Gambia EPI schedule (schedule 1) and an adapted WHO recommended age range (schedule 2)  [7]. TheA total of 44,544 children were included in this analysis; 77.5% from URR, 16.1% from NBR, 1.2% from LRR, 2.1% from WR and 3.2% from the Greater Banjul health facilities. As the sample sizes from each geographical region varied substantially results are presented by study site.Vaccination coverage and age distribution at time of vaccination were similar across all geographical regions  and 3.BCG uptake was high with over 95% coverage in all areas. The median age of BCG vaccination was just under 2 weeks in the urban WR, and around 3–4 weeks in the rural areas of NBR, URR and LRR.A high coverage of the primary series was achieved in all geographical regions. Coverage of the first dose of DPT ranged from 93.2% in NBR to 99.8% in the Greater Banjul health facilities. Coverage for two doses ranged from 90.1% in URR to 99.8% in the Greater Banjul health facilities. A slightly lower coverage of three doses of DPT was observed across all regions; ranging from 81.7% in URR to 99.0% in Greater Banjul clinics. The median age that DPT doses were received ranged between 2.5 (IQR 2.1–3.0) and 2.8 (IQR 2.3–3.6) months for DPT1, between 3.9 (IQR3.4–4.7) and 4.4 (IQR3.7–5.7) months for DPT2 and between 5.3 (IQR 4.6–6.4) and 6.2 (IQR 5.0–8.0) months of age for DPT3, with West Kiang being closest to the prescribed schedule. Measles vaccination coverage ranged from 83.3% in URR to 97.0% in Greater Banjul clinics. The median age for measles vaccination was similar across all regions, ranging from 9.0 (IQR 8.5–9.6) to 9.9 (IQR 9.2–11.0) months. The coverage for the DPT booster dose was much lower compared to those of the primary series; ranging from 43.9% in the WR to 82.8% in West Kiang. The median age ranged between 18.0 (IQR 16.4–19.7) and 19.2 (IQR 17.4–21.5) months.The proportion vaccinated by age for each vaccine was estimated using 1 minus the Kaplan-Meier survival function . FurtherUsing schedule 1, the proportion vaccinated on time with DPT1 ranged from 55.8% (95% CI: 55.31–56.36) in URR to 96.1% (95% CI: 94.1–97.5) in West Kiang, LRR. The proportion vaccinated on time with DPT2 ranged from 34.4% (95% CI: 33.90–34.92) in URR to 90.1% (95% CI: 87.64–92.75) in West Kiang, LRR. For DPT3, only 20.3% (95% CI: 19.84–20.70) of URR children were vaccinated on time compared to 65.8% (95 CI: 61.67–69.92) in West Kiang. For measles vaccine, coverage by 10 months of age ranged from 46.1% (95% CI: 45.51–46.61) in URR to 73.0% (95% CI: 69.01–76.91) in West Kiang. The coverage of the DPT booster dose by 19 months of age was less than 40% in children from URR, NBR and the Western regions. 72.3% (95% CI: 67.94–76.59) of children vaccinated with the DPT booster dose in West Kiang, did so on time .Using schedule 2, the patterns on time vaccination coverage was similar to schedule 1 but at higher coverage .Overall, compared to other study sites, a higher proportion of children in the URR region were delayed for all vaccinations (Table 3). Children from West Kiang were more likely to return on time for vaccination. For BCG vaccine, the proportion experiencing delays ranged from 2.0% in West Kiang to 14.6% in URR. An increasing proportion of children were delayed with increasing number of DPT doses for all study sites; ranging from 1.0%–18.8% for DPT1 and increasing to 5.2%–24.8% for DPT3. For those vaccinated with measles vaccine, the proportion who delayed ranged from 1.3% in West Kiang to 19.3% in the Western health region. Very few children in West Kiang were delayed for DPT4 (0.55%) compared with 11% of children in URR.Details of predictors for delay to vaccination for each study site are shown in Tables S2–S6 in The Gambia health system achieves high vaccine coverage in the first year of life. Vaccination is offered for free and there are mobile services for remote populations. As a result, vaccination coverage is over 95% for BCG, >93% for one dose of DPT, and approximately 90% for 2 doses of DPT. Coverage of the third dose of DPT and measles are lower, particularly in the URR and NBR rural areas vaccines. Timeliness also has implications for the introduction of other vaccines. Until recently, due to safety concerns, there was an age restriction on the rotavirus vaccine schedule Children receive DPT1 usually between 2–3 months, DPT2 between 3 and 4.5 months and DPT3 between 4–6 months of age. This observation has important implications, not only for the success of the DPT vaccines but also for the other vaccines delivered at these times points, i.e. PCV, HepB, OPV and Hib We explored the estimated proportion vaccinated by age and predictors for delayed vaccination. These are important indicators for ensuring that vaccines are being delivered before a child is at risk of acquiring infection and also to develop strategies to improve age-appropriate vaccination coverage Previous delay in vaccinations was associated with further delay in later vaccination rather than a reversion to the original schedule. This applied not only to the primary series but also to measles and DPT booster doses, suggesting that this may reflect not only a scheduling knock-on effect but also a tendency for families who delay initially to continue doing so. Early delayers may be a group needing the specific attention of the health staff.This study had potential weaknesses: The DSS data sets depend on interviewers visiting each home and it is possible that not all households were visited or all records were adequately collected. For NBR, this data set represented 59.8% all births in this region between 2005 and 2012. As noted by Payne and colleagues, those not surveyed were more likely to come from urban areas and have higher educational and wealth levels We did not take into account mortality and some children may have died before being eligible for vaccination. To include these children may have underestimated vaccine coverage and increased the estimate of the magnitude of delay. The design of this work also assumes that those with a vaccine date had been vaccinated and those with missing vaccination dates were not vaccinated. The presence of a vaccination card may be associated with a greater probability of being vaccinated EPI was initiated in the Gambia in the same year as the Primary Health Care (PHC) strategy. The primary aim of PHC was “making health care more accessible and affordable to the majority of Gambians” File S1This file contains Table S1–Table S6. Table S1. Estimated proportion vaccinated by age, vaccine type and geographical region in the Gambia. Table S1a. North bank region. Table S1b. South bank, Upper River Region. Table S1c. West Kiang, Lower River region. Table S1d. Western health region. Table S1e. Greater Banjul Health facilities, DPT booster dose not recorded. Table S2. North bank region: Proportion delayed to vaccination and predictors for delay by vaccine type using the adapted WHO recommended vaccine schedule. Table S2a. BCG, delay if vaccinated after 8 weeks of age. Table S2b. DPT1, delay if vaccinated after 3 months of age. Table S2c. DPT2, delay if vaccinated after 5 months of age. Table S2d. DPT3, delay if vaccinated after 7 months of age. Table S2e. Measles vaccine, delay if vaccinated after 12 months of age. Table S2f. DPT-booster dose, delay if vaccinated after 24 months of age. Table S3. South bank, upper river region. Proportion delayed to vaccination and predictors for delay by vaccine type using the adapted WHO recommended vaccine schedule. Table S3a. BCG, delay if vaccinated after 8 weeks of age. Table S3b. DPT1, delay if vaccinated after 3 months of age. Table S3c. DPT2, delay if vaccinated after 5 months of age. Table S3d. DPT3, delay if vaccinated after 7 months of age. Table S3e. Measles vaccine, delay if vaccinated after 12 months of age. Table S3f. DPT-booster dose, delay if vaccinated after 24 months of age. Table S4. West Kiang, Lower river region. Proportion delayed to vaccination and predictors for delay by vaccine type using the adapted WHO recommended vaccine schedule. Table S4a. BCG, delay if vaccinated after 8 weeks of age. Table S4b. DPT1, delay if vaccinated after 3 months of age. Table S4c. DPT2, delay if vaccinated after 5 months of age. Table S4d. DPT3, delay if vaccinated after 7 months of age. Table S4e. Measles vaccine, delay if vaccinated after 12 months of age. Table S4f. DPT-booster dose, delay if vaccinated after 24 months of age. Table S5. Western health Region EPI cluster survey. Proportion delayed to vaccination and predictors for delay by vaccine type using the adapted WHO recommended vaccine schedule. Table S5a. BCG, delay if vaccinated after 8 weeks of age. Table S5b. DPT1, delay if vaccinated after 3 months of age. Table S5c. DPT2, delay if vaccinated after 5 months of age. Table S5d. DPT3, delay if vaccinated after 7 months of age. Table S5e. Measles vaccine, delay if vaccinated after 12 months of age. Table S6. Greater Banjul health Clinics. Proportion delayed to vaccination and predictors for delay by vaccine type using the adapted WHO recommended vaccine schedule. Table S6a. BCG, delay if vaccinated after 8 weeks of age. Table S6b. DPT1, delay if vaccinated after 3 months of age. Table S6c. DPT2, delay if vaccinated after 5 months of age. Table S6d. DPT3, delay if vaccinated after 7 months of age. Table S6e. Measles vaccine, delay if vaccinated after 12 months of age.(DOCX)Click here for additional data file.


S. pneumoniae serotype 1 were genotyped by MLST. Serotype 1 was recovered from 87 (0.71%) of 12,319 NPS samples collected. In the pre-vaccination period, prevalence of serotype 1 was 0.47% in both study arms. In the post-vaccination periods, prevalence in the fully vaccinated villages ranged between 0.08% in period 1 and 0.165% in period 2, while prevalence in partly vaccinated villages was between 0.17% in period 3 and 1.34% in period 2. Overall, four different genotypes were obtained, with ST3081 the most prevalent (60.71%), followed by ST618 (29.76%). ST3081 was found only in post-vaccination period 2 and 3, while ST618 had disappeared in post-vaccination period 3. Distribution of these major genotypes was similar in both study arms. Emergence of ST3081 and concomitant disappearance of ST618 may suggest a change in the molecular epidemiology of pneumococcal serotype 1 in this region. This change is not likely to be associated with the introduction of PCV-7 which lacks serotype 1, as it was observed simultaneously in both study arms. Future population-based epidemiological studies will provide further evidence of substantive changes in the pneumococcal serotype 1 epidemiology and the likely mechanisms.Streptococcus pneumoniae serotype 1 is one of the leading causes of invasive pneumococcal disease. However, this invasive serotype is hardly found in nasopharyngeal asymptomatic carriage and therefore large epidemiological studies are needed to assess the dynamics of serotype 1 infection. Within the context of a large cluster randomized trial conducted in rural Gambia to assess the impact of PCV-7 vaccination on nasopharyngeal carriage, we present an ancillary analysis describing the prevalence of nasopharyngeal carriage of pneumococcal serotype 1 and temporal changes of its more frequent genotypes. Nasopharyngeal swabs (NPS) were collected before PCV-7 vaccination (December 2003–May 2004) and up to 30 months after PCV-7 vaccination. The post-vaccination time was divided in three periods to ensure an equal distribution of the number of samples: (1) July 2006–March 2007, (2) April 2007–March 2008 and (3) April 2008–Feb 2009.  Streptococcus pneumoniae is usually found in the nasopharynx of healthy individuals, which is considered a necessary step preceding invasive pneumococcal disease (IPD), including pneumonia, meningitis, and bacteraemia  include this serotype and therefore understanding the dynamics of serotype 1 carriage has become a priority. Within the context of a cluster-randomized trial conducted in rural Gambia , we collThis study was an ancillary study of large pneumococcal carriage studies conducted in 21 selected villages in rural Gambia as previously described . FirstlyNP swabs were collected as part of several ongoing studies. First, a large pre-vaccination cross-sectional survey (CSS) conducted in 2003–2004, prior to a PCV-7 randomized trial . Later, Approval for this study was obtained from the Joint Medical Research Council (MRC)/Gambia Government Ethics Committee and the Ethics Committee of the London School of Hygiene & Tropical Medicine, UK . Community and individual consent was obtained from study participants and the conduct of the trial was guided by a Data Safety and Monitoring Board.S. pneumoniae serotype 1 isolates obtained from NP swabs during a survey were identified by latex agglutination  was obtained by submission of sequences onto the MLST database website.All statistical analysis were carried out in STATA  using Chi-square tests. S. pneumoniae in the pre-vaccination period was 71.78% . The overall prevalence of S. pneumoniae in the post-vaccination periods 1–3 was 47.08% .A total of 12,319 NP samples were collected during the study: 22.2% of which were from the pre-vaccination period and 32.4%, 28.2% and 17.2% from the post-vaccination study periods 1–3, respectively. The median age of sampled individuals was 15 years (IQR 5.9—45 years), 11 years (IQR 4.7—29 years), 11 years (IQR 5.6—27 years) and 14 years (IQR 6.7—33 years), in the pre-vaccination and post vaccination periods 1–3 respectively. The overall prevalence of S. pneumoniae serotype 1 was 0.71% . Prevalence of serotype 1 carriage was highest (1.02%) among children aged 5–14 years (p < 0.001) compared to other age groups. Serotype 1 carriage prevalence was highest in post-vaccination period 2 (1.50%) compared to the other study periods (p < 0.001)  .p = 0.268) but these were not statistically significant.Serotype 1 isolates were likely to be found during the wet season 0.81%  compared to the dry season 0.64%  (p = 0.703). In the pre-vaccination study period, prevalence of carriage of serotype 1 was the same in both vaccinated and control villages (0.47% each). However, the prevalence was lower in vaccinated than in control villages in post-vaccination period 1 , similar in vaccinated and control villages in period 2  and higher in vaccinated villages in period 3   .p = 0.368). However, the distribution of STs differed over the course of the study (p < 0.001). ST3081 was seen only in the post vaccination periods. ST618 was seen in the pre-vaccination and periods 1 and 2 post vaccination, but not in the post vaccination period 3 (p = 0.002) and control (p = 0.021) villages . Four different STs were obtained, with ST3081 being the predominant ST (60.71%) in both vaccinated and control villages followed by ST618 29.76%), ST217 (7.14%) and ST303 (2.38%). Prevalence of different STs was not associated with age groups (period 3 . Differevillages , with thvillages  and 2.9.76%, STGiven that pneumococcal serotype 1 is one of the common cause of IPD worldwide and the paradox of its’ rarity in nasopharyngeal carriage, it is not unsurprising that only a few published studies have evaluated serotype 1 carriage patterns. To our knowledge, this is the largest study evaluating the dynamics of pneumococcal serotype 1 carriage. We present findings from as many as 87 serotype 1 isolates and report on the prevalence and dominant genotype patterns over a 6 year period. The finding of 0.71% overall prevalence in carriage of serotype 1 agrees with earlier findings indicating the rarity of serotype 1 in carriage studies . We alsoIntroduction of the pneumococcal conjugate vaccine PCV-7 is associated with a reduction in carriage of VT serotypes but has also been linked to an increase in carriage of NVT in some settings  but not All STs obtained in this study belong to the ST217 hyper virulent clonal complex responsible for several epidemic outbreaks in West Africa . The preHowever, we acknowledge some limitations with this study. Firstly, the samples in this study were of modest size and a larger sample size would have allowed for more robust analysis between the comparison groups. The modest number we got after sampling such a large population goes to support the notion that serotype 1 is rare in carriage. Obtaining a much larger sample size will therefore require very large epidemiological studies and its attendant challenges. Secondly, this study was limited to carriage isolates from the Western division of The Gambia. It is unclear if observations from this group are applicable to a more heterogeneous population. There is therefore a need for further studies in The Gambia, including population-based molecular epidemiological studies assessing the distribution of these STs causing IPD and whole-genome comparisons in order to identify genetic differences that could correspond with the observed differences between otherwise highly similar strains, and such studies are currently underway .In conclusion, in this study we show the prevalence of pneumococcal serotype 1 carriage as well as the predominant genotypes and how they varied over the study periods, but this did not seem related to community vaccination with PCV-7. This provides important baseline data for further evaluation of nasopharyngeal carriage after PCV-13 has been introduced in The Gambia.


The aim of this prospective pilot study was to test how melatonin levels follow the circadian cycle in ICU patients. There is strong evidence that changes of circadian rhythm are reflected in melatonin levels with peak levels at dawn and low levels during daytime . The ICUMelatonin levels were determined in eight medical ICU patients on mechanical ventilation, without brain injury or infection. Arterial blood samples were taken on the day of admission at 18:00 (TE0) and 03:00 in the morning (TM0), then at the same time points 48 hours later . Blood samples were centrifuged at 3,000 rpm for 8 minutes, and then serum samples were stored at -80°C. Measurements were performed using a US-CEA908Ge melatonin ELISA kit. For statistical analysis, a binary (yes/no) variable was created from the pairs for each day, assigning 'Yes' if the TE values were greater than TM (melatonin peak reversion). The proportion of reversals and their 95% confidence intervals were estimated using a GEE model for repeated binary data, assuming a binomial distribution and log link, and accounting for subject as a repetition factor. All calculations were done in SAS 9.4.Melatonin levels were not normally distributed and were ranging between 9.2 and 23.7 pg/ml at T0 and 11.3 and 17.9 pg/ ml at T1. The median differences of the morning and evening serum melatonin levels were: TM0 - TE0 = -2.8 (-3.8 - (-0.2)); TM1 - TE1 = -1.2 (-2.5 - (-0.4)) presented as median (IQR). The proportion of subjects with peak reversals was 92.9% (80.8 to 100.0%).Our preliminary data suggest that circadian rhythm disturbances may occur in critically ill patients within 48 hours after admission, and can be detected by inversion of melatonin peaks. Despite the limitations of this study, it may justify the need for larger observational and randomized trials on the effect of light on melatonin levels and on outcomes in ICU patients.


Lactobacillus plantarum is a widespread member of the Lactobacillus genus and frequently isolated from spoiled acidified food products. Here, we report the draft genome sequences of three L. plantarum food isolates. Lactobacillus plantarum is a widespread member of the Lactobacillus genus and frequently isolated from spoiled food products, but it is also exploited for its probiotic traits , SSPACE version 2.3 . CLC Genomics Workbench version 6.0.1 (sion 2.3 , and Gapsion 2.3  were usesion 2.3  was usedL. plantarum strains have been deposited at DDBJ/EMBL/GenBank under the accession numbers listed in The genome sequences of the three


This study examined the characteristics of vertebral artery hypoplasia in 346 arteries of adult black Kenyans. The circumference was measured on haematoxylin/eosin stained microscopic sections of the distal one-third of the intracranial vertebral arteries using scion image analyser. Internal diameter was calculated in millimetre. Data were analysed using SPSS version 16.0. Vertebral artery hypoplasia (diameter < 2.0 mm) occurred in 100 (28.9%) arteries. Sixty of these (17.3%) were on the left and 40 (11.6%) on the right. Sixty (17.3%) were in females while 40 (11.6%) were in males. The side and gender differences were statistically significant at confidence interval of 95%. Frequency of vertebral artery hypoplasia was higher than in most other populations studied. The condition differs from that in other populations because it is more common on the left side and in females. We recommend ultrasound, angio-CT, or angio-MRI evaluation of vertebral arterial system before diagnostic or interventional procedures on posterior circulation. Vertebral artery hypoplasia (VAH) refers to those arteries with diameter of less than 2.0 mm –3. This These characteristics of VAH show ethnic variation , 14. As Two hundred and seventeen formalin fixed brains from adult black Kenyans obtained during autopsy at the Department of Human Anatomy, University of Nairobi, Kenya, were available for the study. Ethical approval was granted by the Kenyatta National Hospital/University of Nairobi Ethics and Research Committee. Forty-four were excluded—30 for suspected cerebrovascular disease and 14 for damage to the arteries. The cases of stroke and other cardiovascular disease were excluded to minimize the potential confounding effect of pathological conditions such as, for example, atherosclerotic, arterial narrowing. One hundred and seventy-three brains  were examined. Only cases of noncardiovascular death, as determined at autopsy, were included. The main causes of death were trauma (60.1%), infections (21.4%), malignancy (13.3%), poisoning (3.5%), and drowning (1.7%). The age distribution of the cases is as shown in © image analyser. Only complete sections were included. Diameter in millimetres was calculated from the formula D = C/π where D is the diameter, C is the circumference, and π = 3.14. The average diameter of the 10 sections was taken to be the diameter of that artery. Vertebral artery hypoplasia was defined as internal diameter equal to or less than 2 mm. Photographs of representative samples of asymmetry were taken using a high resolution digital camera. Data were analysed using SPSS version 16.0 for Windows. Gender differences were analysed using the Student's t-test at 95% confidence intervals where P value ≤ 0.05 was taken as significant. Results are presented in digital macrographs, tables, and bar charts.The cardiovascular risk factors revealed included alcohol (32.3%), diabetes mellitus (23.4%), cigarette smoking (20.8%), and obesity (14.5%). The brains were divided into those of males and females. Arachnoid mater was gently peeled from the brainstem to expose vertebral and basilar arteries. Two millimetre specimens taken from the distal one-third of the intracranial vertebral artery were fixed in 10% formalin and processed for paraffin embedding and sectioning. Ten five micron serial sections from each arterial site were stained with haematoxylin/eosin and examined with light microscope at magnification ×40. The images taken by photomicroscope were digitized and internal circumference of each of the 10 sections from each site of the artery determined using scionP = 0.047).In all cases, two vertebral arteries joined to form the basilar artery. One hundred and two (29.5%) were symmetrical , while 2P = 0.034). The peak diameter range was 2.6–3.0 mm, present in 136 (39.3%), followed by 2.1–2.5 mm (20.2%). Forty arteries (11.6%) measured >3 mm. Two hundred and forty-six (71.1%) were normal with diameter >2.0 mm. One hundred cases (28.9%) measured 2.0 mm and less; that is, they were hypoplastic . The mean diameter was higher in females (3.13 mm) than that in males (2.29 mm). The difference was statistically significant (oplastic . Of thesoplastic . Twenty-oplastic . Twenty-P = 0.034)  .Observations of the current study that only 29.5% of vertebral arteries are symmetrical are consistent with the literature reports –18. ThisThese figures indicate wide variations in the diameter of vertebral arteries. Although such variations may be attributed to methodological factors, they probably reflect population differences .The current study reveals a 28.9% prevalence of VAH, higher than 2.34–26.5% reported for most Caucasian –25 and IThe most remarkable observation of the present study is the left side predominance of VAH. This is at variance with most literature reports which show right side predominance , 22, 28.The present study reveals a male predominance, at variance with contemporary literature reports , 22, 31.Vertebral artery hypoplasia occurs in about 30% of black Kenyans studied, higher than in most other populations studied. It also differs from other populations in that it is more common on the left side and in females. We recommend ultrasound, CT-angio or angio-MRI evaluation of vertebral arterial system before diagnostic or interventional neurosurgical and neuroradiological procedures on posterior circulation.


Hook plates are used to treat acromioclavicular joint dislocations. Our study took into consideration the patients’ outcome following treatment with clavicular hook plates retained for more than five months.Our aim was to assess the response to treatment of acromioclavicular joint dislocation by clavicular hook plate when retained for more than five months.We treated 24 patients who had acromioclavicular joint dislocation with a clavicular hook plate between 2008 and 2012 at our hospital. We did not repair the coracoclavicular ligament. In all patients, the plate remained more than five months because they did not come back at the recommended time for removal of their plates. The follow-up period ranged from five to thirty three months with a mean of nineteen months.The main complication was osteolysis that was seen in two patients. The mean constant score was 94.5 ± 8.77 out of 100 with a range between 70 and 100.Our study showed that the use of clavicular hook plates was a good treatment option for acromioclavicular joint dislocation. However, scores were lower in case of prolonged presence of plates. There are different options for treatment of acute acromioclavicular joint dislocations -4. TheseThe objective of this study was to evaluate the outcome of surgical treatment of acute acromioclavicular dislocations (types III and V) using fixation with a hook plate, without coracoclavicular and acromioclavicular ligament reconstruction in patients who did not refer for removal of plates for at least five months.A total of 46 patients with acromioclavicular joint dislocation were treated with hook plate in our hospital from 2008 to 2012. Our study was a retrospective investigation. We excluded 17 patients whose plates were removed before five months from the beginning of the study. In five cases we could not contact the patients. The remaining 24 patients were included in our study. Acromioclavicular joint dislocations were treated with hook plates without repairing the coracoclavicular ligaments in these patients. In all patients, the plate remained at least for five months. Regarding the typing, four patients had Rockwood type III (16.7%) and twenty patients (83.3%) had Rockwood type V dislocations . There wOur patients did not experience infection or plate failure during this study. We used a constant score for pain severity (15), range of motion (40), forward flexion (10), abduction (10), internal rotation (10), external rotation (10) of shoulder, activity level (20), patients’ condition regarding sleep (2), exercise (4), work (4), positioning in space (10), and power (25) with a total score of 100. The mean score pain severity was 14.29 ± 0.9 out of 15 (range 12 - 15). The mean score of activities and positioning in space was 18.45 ± 2.35 out of 20 (range 12 - 20). The mean score of range of motion was 37.58 ± 4.86 out of 40 (range 22 - 40). The mean power score was 23.75 ± 1.87 out of 25 (range 19 - 25), and the mean of constant score was 94.5 ± 8.77 out of 100 . The min Many operations and different types of devices have been used to treat acromioclavicular dislocations with different outcomes , 3-6, 9.


The aim of the study was to assess the possibility of preoperative levosimendan (LS) administration in myocardial reserve evaluation and choice of the method of surgical treatment in patients with chronic heart failure (CHF).LS was used in 107  patients (mean age 53 ± 3 years) as a component of CHF therapy to prepare them for the surgical intervention (2 to 4 days before surgery). In total, 44.9% of the patients had CHF caused by noncoronarogenic dilated cardiomyopathy and 55.1% by ischemic cardiomyopathy. Indication for LS therapy was left ventricular ejection fraction (EF) <35% (28 ± 6%). Seventy percent of patients had mitral insufficiency (MI), grades II to IV, 63% tricuspid insufficiency (TrI), grades II to III, 84% pulmonary hypertension (PH), 47% arterial hypertension, grades II to III, and 27% of the patients had left ventricular aneurysm. Mean level of BNP was 1,803 ± 124 pg/ml. LS was administered as i.v. infusion in doses of 0.025 to 0.1 μg/kg/minute without previous bolus injection. Mean duration of infusion was 27.5 ± 5.3 hours. After infusion all patients underwent control assessment of values. All patients were operated: 25 (23.3%) underwent reverse cardiac remodeling, 63 (58.9%) myocardium revascularization (MR) with mitral or aortic valve replacement, 17 (15.9%) MR and/or resection of left ventricular aneurism and two (1.9%) heart transplantation.Heterogeneity of LS effects was registered in a number of values. The most significant positive effect which allowed one to evaluate myocardial reserve was demonstrated by decrease of PPA (93.5% of patients) and increase of EF (77.6% of patients). The most significant changes were also noted in decrease of TrI, PH and MI . In 69.2% of patients with noncoronarogenic dilated cardiomyopathy the effect of LS exposure was marked. In the majority of patients with ischemic cardiomyopathy the effect was moderate. In case of the absence of LS-positive effect, perioperative use of mechanical circulatory support was considered.Preoperative use of LS allows one to evaluate myocardial reserves and prepare high-risk patients with CHF for surgery. Our findings may serve as one of the additional criteria to choose the type of surgical treatment: reconstructive surgery  or heart transplantation.


Since then, only limited data were available. Our Anthropometric, educational and morbidity data of persons above 18 y were registered in all geographical regions of Hungary, at primary care encounters and within community settings.obesity was: under 35 y = 32.5%-16.2%, between 35-60 y = 40.6%-34.7%, over 60 y = 44.3%-36.7%. Among women, in the same age categories were: 17.8%-13.8%, 29.7%-29.0%, and 36.9%-39.0%. Data were presented according to age by decades as well. The highest odds ratio of overweight  was registered by middle educational level, the lowest odds ratio of obesity  by the highest educational level. The highest proportion of obese people lived in villages (35.4%) and in Budapest (28.9%). Distribution of overweighed persons were: Budapest (37.1%), other cities (35.8%), villages (33.8%). Registered metabolic morbidities were strongly correlated with BMIs and both were inversely related to the level of urbanization. Over the previous decades, there has been a shift in the distribution of population toward being overweight and moreover obese, it was most prominent among males, mainly in younger generation.Data  of 40,331 individuals  were analyzed. Overall prevalence for overweight was 40.4% among men, 31.3% among women, while for obesity 32.0% and 31.5%, respectively. Abdominal obesity was 37.1% in males, 60.9% in females. Among men, the prevalence of overweight-Evaluation covered 0.53% of the total population over 18 y and could be very close to the proper national representativeness. The threat of obesity and related morbidities require higher public awareness and interventions. Obesity, a worldwide pandemic, is well-known for the readers who are interested in metabolic diseases with high public health impact. While obesity is mainly a medical problem, its related metabolic, cardiovascular and other diseases have serious public health and other economic or social implications. Health care services provided for obese patients are usually more expensive, mainly for the complications related to this condition. The increasing ratio of overweight and obese people is visible in all health care settings and also in public places. It has been described as a world-wide trend, although there are differences between and within countries and populations , 2.A similar trend was observed in previous Hungarian evaluations, although the issue and importance of obesity were realized later than in other countries , 4.Measuring and registering anthropometric parameters is rarely obligatory at different levels of health care provision, let alone in the “healthy” population. Although measuring everyone in a society is impossible, finding and reaching the required representation is crucial. Studies and surveys in other countries have used quite different methods for the selection of participants and so have the Hungarian ones , 5. Repr16,641 individuals  were collected by trained staff of the National Institute of Food Hygiene and Nutrition [2, between 35-59 year = 26.3 kg/m2, between 60-74 year = 26.7 kg/m2 and above 75 year = 25.8 kg/m2. Due to the earlier retirement age of women, other groups were formed for them resulting these data: 19-34 year = 23.3 kg/m2, 35-54 year = 26.0 kg/m2, 55-74 year = 28.1 kg/m2 and above 75 year = 27.0 kg/m2. Within all age groups, the prevalence of overweight was 41.6% for men and 32.1% for women, while obesity was recorded in 11.6% and 18.1% of men and women, respectively.The first wide range Hungarian study was performed between 1985 and 1988. It was a professionally planned survey with wide geographical distribution, targeting the whole population of the country. Morbidities, anthropometric parameters, nutritional habits and living circumstances were registered. Data of utrition . The fol2,568 people of different ages. Among the 1,164 men examined, the prevalence of overweight was 41.9%, and that of obesity was 21.0%. Overweight was recorded in 27.9%, obesity in 21.1% of the 1,404 females who participated in the survey [A similar but smaller professional study was conducted between 1992 and 1994 measuring altogether Ten years later, in a survey among incidentally involved primary care patients between 40-70 y of age, 45% prevalence of overweight and 32% of obesity was diagnosed, 3% of them with morbid obesity .According to the WHO database, the prevalence of obesity was 26.2% among Hungarian males and 22.9% among females. Overweight was found 65.8% and 49.4% among males and females, respectively, increased by age, although the sources of data were not clearly described .1,165 people. The means of BMI in the selected age groups of men were as follows: 18-34 y = 25.0 kg/m2, 35-64 y = 28.4 kg/m2 and over 65 y = 28.7 kg/m2. The same data for women were 23.6 kg/m2, 28.1 kg/m2 and 29.8 kg/m2, respectively. Obesity was diagnosed in 26.2% of men and in 30.4% of women, while morbid obesity was presented in 3.1% and 2.6%, respectively. Abdominal obesity was more prevalent among women than men (51.0% vs. 33.2%) and its ratio increased parallel with age in both genders [In 2009, a nationwide study targeted to select participants representatively, achieved only 35% response rate. Health workers measured the anthropometric parameters of 27,746 responders who filled the questionnaires. Among males, according to the self-measured data, overweight was reported by 31.5%, 43.5% and 49.6% in the age groups of 18-34 y, 35-64 y and over 65 y, respectively, while these figures were 17.8%, 33.6% and 39% among females. Within the same age categories, obesity was measured at 14%, 30.8% and 26.4% among men and at 12.5%, 27.4% and 28.4% among women. Irrespectively of age, self-measured overweight was reported by 40.6% of men and 30.5% of women, obesity by 25.0% and 23.6% [At the same time, another survey was conducted via the internet in various regions of Hungary involving 18,763 policemen and 2,037 policewomen (20-55 year), the prevalence of obesity was 19.1% and that of overweight was 43.8%. The distribution of waist circumference between 94-102 cm was 21.9%, above 102 cm was 22.6%. The ratio of obese officers increased with the age; it was 11.8% (between 20-25 year) and as high as 29.3% (between 40-45 year). Geographical differences were also recorded. Obesity was presented in 15.3% among policemen who served in the capital, and in 19.4% among those who were country-based [A specific professional group was selected for a survey in 2002. Among Since reliable, updated data of the Hungarian population are lacking, our main goal was to fit this gap. Collecting and presenting new data and comparing them to figures of the last wide range survey of 25 years before was aimed. Without governmental support, we approached primary care providers.Our study was conducted between September 2012 and April 2013, at primary care encounters and during community activities of primary health care staff including occupational health services as well, in all geographical regions in Hungary. Only non-institutionalized adults from 18 years of age were involved on a voluntary basis.The participating family physicians (GPs) were given a detailed written description of methods for anthropometric measurements and asked to recruit the first 200 persons (over 18 y) visiting their office or persons who were seen by their community activities. They were asked to fill a written or electronic data sheet with the figures below.Only those patients were excluded whose conditions might have been influenced by morbidities with weight consequences . Exclusion was decided by the GP.stadiometer, when head positioned in Frankfort plane (an imaginary line from lower border of the eye orbit to the auditory meatus).Persons on barefoot, measured with approved Measured with a regularly calibrated weighing machine, in light clothing, fasting and with empty bladder, after defecation.Using a professional tape .All data were expressed in round figures.diabetes and/or hypertension) was also registered.The presence or absence of metabolic disease (under), completed only elementary school (primary), graduated in secondary school and/or skilled worker qualification (secondary), having university or college degree (higher).The participants’ highest achieved level of education: not completed the 8-year elementary school .The WHO-established waist circumference, the upper limit of normal range was 94 cm for men and 80 cm for women, the “risky” range was between 94-102 and 88-94 cm respectively, and abdominal obesity was diagnosed above these values.Regarding Stata 9.2.programme.Descriptive statistics were done. Proportions were calculated with 95% confidence intervals. Univariate and multivariate logistic regression models were created to check the associations between the outcome and its influencing factors. Odds ratios were reported with their 95% confidence intervals. Statistical analyses were performed in 41,163 subjects were collected and 40,331  were analyzed, because of missing or incomplete records.Altogether, the data of Coming from all parts of Hungary, the number of participating GPs was 244, representing 3.5% of all primary care practices. The location and number of practices were as follows: Budapest, the capital of Hungary: 38, cities and towns: 99, and villages: 107.The Tables Increase in waist circumference, already in the younger generation is visible among figures of the Table According to waist circumference, parameters of risk were identified among more men in rural than urban settings. In their fourth decade of life (30-39 year), the ratio of males at risk was much higher (20.0% vs. 26.8%) in the rural population and in the fifth decade (40-49 y) it was still higher (31.5% vs. 36.4%). A similar trend was observed among rural women (38.2% vs. 54.9%) in their forties and (63.8% vs.75.5%) above 70 (years of age).obese category. Men with a higher degree had the highest proportion among the overweight BMI group and also higher in the normal then in obese group, while females had the lowest record among the obese and the highest in the normal range. Similar results were found according to waist circumference. In the categories of obesity (regarding BMI and waist circumference) there were inverse relations between odds ratios and degrees of education.Table In both genders, these differences were mostly statistically significant when comparing primary and other educational levels.obesity was the highest in the villages (35.4%), the lowest in Budapest (28.9%). Overweight was “only” (33.9%) in the villages, the highest in Budapest (37.1%) and 35.8% in the cities. Persons within normal BMI range were only 31.8% in Budapest. They represented the 32.5% of other urban and 28.6% of rural population.The prevalence data for As presented in Table Comparing the data of a quarter century ago, the BMI has become higher in all age categories and the distribution of the population also tended toward being overweight, moreover obese, resulting a 2-4-fold increase in the percentage of incidence in some age groups. This shift has been more prominent among males. Their BMIs have been higher from the middle decades, while earlier women used to have larger surplus, which means rearrangement between categories, a shift from being overweight to becoming obese.Significant differences were found between the educational level and BMI categories. Although there were fewer obese persons among the subjects with higher education, being overweight was common, while women with a higher degree were less obese.Registered metabolic morbidities were strongly correlated with BMI and both were inversely related to the level of urbanization.0.16% of the whole population [0.53% participation rate in the age-cohort over 18 years. This ratio is much higher than that of the similar surveys in other countries. Data regarding education and waist circumference have not been compared or analyzed before. Another problem emerged, because the distribution of data within different age-cohort regarding gender was not identical. Earlier, the official retirement age was 55 years for women and 60 years for men. We tried to present our data considering the grouping of this survey as well. Previously, 20 kg/m2 was used as a lower threshold of normal BMI-group, but the WHO has recently introduced the limit of 18.5 kg/m2.Previous Hungarian studies used different methods and other age categories for the selection of participants; therefore it was often difficult to make proper comparison. Most of these studies had a much lower number of participants , 6–10. Apulation . CurrentComparing our data to that of neighboring countries, these figures are higher although they were given almost within the same range in the WHO database , 11. In Although Hungary is situated mainly in lower terrains (the highest mountain is 1014 m above sea level) there were only small differences (100-300 m) regarding altitudes between geographic locations of GPs. It is not surprising that data were mainly similar without such differences as presented in a study from the US, with lower registered BMI of persons living in the mountains . Findingobesity pandemic” [There was no more comparison to available data of other countries worldwide, while almost all of them have to face to the “andemic” , 13.People living in smaller settings may have many disadvantages regarding access to healthcare delivery. This reason combined with their lifestyle, which is often not appropriate could be the reason for higher incidence rate of metabolic morbidities and overweight/obesity.under-educated were both 5%, primary and secondary schools were completed by (27% vs. 33%) and (51% vs. 46%) and (14% vs. 15%) had higher educational degree [Requirement regarding representativeness of educational level was properly fulfilled. Comparing the population at large in Hungary and that of the study, The participants of this nationwide survey were mainly primary care patients and less from community settings. Without appropriate registration, the real ratio is unknown. It might be the reason why the peak of the age tree of participants was almost 10 years higher than that of the population at large. Patients with cardiovascular morbidities might have been overrepresented, although prevalence of the 2 registered metabolic diseases (hypertension and diabetes) in the older generation of men was closer to the data of national morbidity register  . There wAlthough anthropometric data were measured by the medical staff, individual inaccuracy could also be encountered, but it could be balanced during under- and over recording.Primary care settings can be a proper place to register and follow up anthropometric parameters and family physicians should be motivated to perform it continuously. Early medical intervention or even advices can help in the prevention of obesity. Proper under- and postgraduate education and use of updated guidelines could be a professional help in daily practices of family physicians, not only in Hungary , 16.Beside the involvement of health workers, much more governmental support, population awareness are needed and clear health policy recommendations should be outlined.