Background. Latex allergy is one of the major health concerns and allergic reactions to latex may be serious and fatal. Purpose. In this study, we sought to determine the frequency of latex hypersensitivity in a group of allergic Egyptian infants and children and its relation to the history provided by the patients or caregivers. Methods. We consecutively enrolled 400 patients with physician diagnosed allergic diseases. The study measurements included clinical evaluation for the site and duration of allergy, history suggestive of latex allergy, family history of allergy, and skin prick testing (SPT) using a commercial latex extract. Results. The study revealed that 16/400 (4%) patients had positive SPT; 11 of them only had positive history of sensitivity to latex. Positive latex SPT was reported in 3.4% (11/326) of patients with bronchial asthma, 5.9% (7/118) of patients with skin allergy, and 4.5% (2/44) of patients with allergic rhinitis. SPT was positive in 7.4% (4/54) of patients with concomitant respiratory and skin allergy. Latex SPT was more specific than sensitive  with a negative predictive value of 99.47%. Conclusion. Although underrecognized, latex is an important allergen in the pediatric age group with a sensitization frequency of 4% among allergic children. It was observed to be especially associated with multiple allergic diseases coexisting in the same patient. Pediatric allergologists should educate their patients on latex allergy and encourage the use of latex-free products. Hevea brasiliensis tree has been widely used in the manufacturing of gloves, balloons, and parts of medical and dental equipment [ Hevea brasiliensis 6 [Hev 6] and Hev b1-13 are recognized as the primary allergens by the International Union of Immunological Societies [Latex as found in nature is a milky sap-like fluid found in 10% of all flowering plants [quipment . Among mocieties . Exposurocieties .Latex sensitization is defined as the presence of immunoglobulin antibodies to NRL products without clinical manifestations . SensitiThe association of latex allergy and allergy to plant-derived foods is called latex-fruit syndrome and is attributed to the cross-reactivity between the major latex allergen hevein and hevein-like domains (HLDs) from fruit class 1 . In patiThis study comprised 400 allergic infants and children enrolled consecutively from the Pediatric Allergy and Immunology Clinic, Children's Hospital, Ain Shams University, and the outpatient clinics of El-Mounira and El-Zawya hospitals over the period from March 2011 to June 2013. Patients included suffered clinical allergic disorders including bronchial asthma (BA), skin allergy, and allergic rhinitis (AR). An informed consent was obtained from the parents and caregivers prior to enrollment. Approval of the local ethics committee was obtained.The diagnosis of BA was established according to the criteria of the American Thoracic Society . The diaAll patients included in the study were subjected to the following.(1) Clinical Evaluation. Clinical history was taken for the allergic disorder and its duration, sensitivity to latex, and exposure to latex containing products including gloves. History of allergy to fruits such as banana and kiwi was also sought. Inquiry was made about the risk factors such as neural tube defects, urogenital anomalies, repeated surgical manoeuvers, and hand dermatitis.(2) Skin Prick Testing. Skin prick tests were performed for each patient using ammoniated allergen extract for latex , positive control (histamine hydrochloride 10 mg/mL), and negative saline control. The procedure was first explained to each patient and/or the caregiver then consent was obtained. First generation short-acting anti-histamines were avoided for at least 72 hours and second generation antihistamines were avoided for at least 5 days before testing. The test sites were marked and labeled at least 3 cm apart, then dropped by the allergen, and gently pricked by sterile skin test lancet. Positive and negative control solutions were similarly applied. Epinephrine was ready in case any systemic reaction occurred. The test result was interpreted after 20 minutes. Largest and orthogonal diameters of any resultant wheal and flare were measured. Pseudopod formation was considered a significant positive reaction. A wheal of 3 mm or more above the negative control was taken as a positive result.(3) Laboratory Investigations. Serum total IgE was measured by quantitative enzyme linked immunosorbent assay (ELISA) . Due to variations of serum IgE with age, the patient's serum IgE value used for data analysis was calculated as a percentage of the highest normal for age. Complete blood counts were done on Coulter Counter .t-test for normally distributed variables and Mann-Whitney test for nonparametric variables. Chi-square (χ2) and Fisher exact tests were used for categorical variables as appropriate. Spearman's correlation test was used. For all tests a probability (P) less than 0.05 was considered significant.SPSS for Windows, release 15.0 , was used for data entry and analysis. All numeric variables were expressed as mean ± standard deviation (SD) or median (interquartile range (IQR)) as appropriate. Comparison of continuous variables was done using Student's The study sample comprised 212 males (53%) and 188 females (47%) . A positHistory of exposure to balloons and rubber toys was positive in 358 (89.5%) patients, to latex bottle nipples in 166 (41.5%), to erasers in 203 (50.7%), and to latex gloves in 105 (26.2%). A history of allergy to fruits, namely, banana, kiwi, and pears, was found in 225 patients (56.25%). The presence of risk factors such as neural tube defect and urogenital anomalies with repeated urinary catheterization was found in 3 (0.75%) and hand dermatitis in 6 (1.5%).The result was positive in 16/400 patients (4% of the studied sample). Seven of our patients (1.75%) had positive latex allergy; that is, they had positive history of allergy to latex products concomitant with positive latex SPT . Among tPositive history of latex allergy was significantly higher among patients with positive latex SPT having a frequency of 77.8% in comparison to 22.2% in those with negative latex SPT. The odds ratio (OR) was 148 . Allergy to fruits was present in 7/16 (43.7%) of the patients who reacted positively to latex SPT versus 218/384 (56.7%) of those with negative result (OR (CI): 0.592 (0.216–1.62); insignificant).X2 = 2.19; P = 0.334).Positive SPT to latex was observed in only 3.2% (9/282) of patients with isolated respiratory allergy and 4.7% (3/64) of patients with isolated skin allergy in contrast to 7.4% (4/54) of patients with concomitant respiratory and skin allergy (Positive SPT to latex was seen in 3.4% (11/326) of all patients with bronchial asthma, 5.9% (7/118) of patients with skin allergy , and 4.5% (2/44) of patients with AR (OR (CI): 0.48 (0.16–1.4); 1.9 (0.6–5.2); 1.16 (0.25–5.2), resp.).P = 0.33, 0.25, 0.98, 0.25, 0.92, 0.73, and 0.477, resp.).The patient's age, duration of exclusive breast feeding, age of weaning, duration of the allergic disease, absolute eosinophilic count, total serum IgE, and IgE percent did not bear a statistically significant relation with positivity of latex SPT  was sensitized to latex. There are no reports on the size of the latex sensitization problem in Egypt. A positive history of exposure to latex products was highly encountered in our cohort of allergic children reaching as high as 89.5% for balloons and rubber toys and 26.2% for latex gloves. Latex containing products such as toys, bottle nipples, and erasers are widely used in Egypt. It is to be noted that most hospitals in Egypt are still using latex-containing medical gloves. However, few dentists and physicians became aware of this problem and started introduction of latex-free medical gloves in their private clinics. Moreover, latex allergens present in sediment and airborne particulate material, derived from tire debris due to heavy urban vehicle traffic and from latex industries in our country , could be important factors in producing latex sensitization. In a study of 326 atopic children, 10 (3%) presented positive skin test to latex, but only five (1.5%) also had a positive clinical history to latex exposure . The preMeglio and associates  studied The corresponding percentage in the general pediatric population is 0.3–4% as reported by some authors . MoreoveIn the present study, 7/16 of those with positive latex SPT gave positive history of allergy to latex. This was a significant finding as compared to those with negative SPT, with a high odds ratio OR (CI): 148 (27–817). The latex SPT was specific rather than sensitive (97.6% versus 77.7%) and showed a high negative predictive value of 99.47%. In an earlier study, the sensitivity of latex SPT was 100% and the specificity was 98% . In chilThe frequency of latex sensitization in all our asthmatic patients was 3.4% 11/326). In a sample of 1097 patients with occupational asthma, 4.9% were found sensitized to latex . A highe. In a saIn our series, 2/44 (4.5%) AR patients had positive latex SPT. In comparison, Airaksinen and colleagues  reportedn = 22) (mean ± standard deviation: 2.09 ± 6.39) but not in those with atopic dermatitis (n = 8) (0.09 ± 0.16) as compared to controls [Our study population included 118 patients with skin allergy  where 7 of them (5.9%) had positive SPT to latex. The incidence of latex allergy among 844 patients under 14 years of age with skin allergy in 2001/2002/2003 was 6.1/11.3/15.9%, respectively, denoting a steady rise . Worth mcontrols .The coexistence of more than one allergic disease in the same patient might increase the possibility of having latex hypersensitivity based on the finding in the present work that 7.4% (4/54) of patients with both respiratory and skin allergy had positive latex SPT in contrast to only 3.2% of patients with respiratory allergy and 4.7% of those with skin allergy.n = 17) (2.89 ± 3.66) with a frequency 52% of latex sensitization among children with spina bifida and urogenital anomalies as denoted by latex specific IgE. In Brazil, a prevalence of 25% for latex sensitization and of 20% for latex allergy was reported among 55 studied patients with meningomyelocele [Our study population included 3 patients with neural tube defects and urogenital anomalies necessitating frequent exposure to latex made catheters. Latex skin prick test was positive in one (25%). Spartà and associates  studied yelocele .In the present study, half of all allergic children had history of fruit allergy (43.7% of patients with positive and 56.7% of those with negative latex SPT). Only 6 out of 222 patients with history of banana allergy (2.7%) had positive latex SPT and only 2/6 had positive history of latex allergy. The only patient who had history of kiwi allergy had positive latex SPT and denied history of latex allergy. Overall, the difference was insignificant (OR (CI): 0.59 (0.2–1.62)) perhaps indicating that history of fruit allergy should be confirmed by SPT or oral challenge before considering it as a risk factor for latex allergy. Other fruits that cross-react with latex such as avocado are not popular in Egypt. Radauer et al. [It is concluded that latex skin sensitization was found in 4% of the studied allergic children, yet latex allergy as determined by a positive self/parental report and positive skin prick test was observed in only 1.75%. Although underrecognized, latex is an important allergen in the pediatric age group. It was observed to be especially associated with multiple allergic diseases coexisting in the same patient. Pediatric allergologists should educate their patients on latex allergy and encourage the use of latex-free products. Studies on the prevalence of latex sensitization in the general population as well as studies on environmental air pollution with latex are recommended.


To evaluate surgical outcomes and prognostic factors for T4 gastric cancer treated with curative resection.Between January 1994 and December 2008, 94 patients diagnosed with histological T4 gastric carcinoma and treated with curative resection were recruited. Patient characteristics, surgical complications, survival, and prognostic factors were analyzed.Postoperative morbidity and mortality were 18.1% and 2.1%, respectively. Multivariate analysis indicated lymph node metastasis  was independent prognostic factor.For patients with T4 gastric cancer, lymph node metastasis was associated with poorer survival. Neoadjuvant chemotherapy or aggressive adjuvant chemotherapy after radical resection was strongly recommended for these patients. Although radical resection had been proved to be the most important indicator of long-term survival for patients with gastric cancer, curative resection for locally advanced gastric cancer, defined as T4 in which the tumor perforates serosa (T4a) or invades adjacent structures (T4b), was associated with increased postoperative morbidity and mortality. This study was approved by the ethic committee of the First Affiliated Hospital of Sun Yat-sen University. Patient information was anonymized and de-identified prior to analysis. Between January 1994 and December 2008, a total of 1249 patients with gastric cancer underwent gastrectomy with curative-intent at Department of Gastrointestinal and Pancreatic Surgery, the First Affiliated Hospital, Sun Yat-sen University. Of these, 132 patients were diagnosed as histological T4 gastric carcinoma, including 94 patients (71.2%) treated with curative resection and 38 patients treated (28.8%) with non-curative resection (R1 or R2 resections). Standard D2 lymph node dissections or D2 plus para-aortic lymph node dissections were performed in these patients with curative intent. A distal subtotal gastrectomy (SG) or total gastrectomy (TG) was performed depending on the location of the primary tumor. The curative (R0) resection was defined as the complete removal of cancer tissue with no residual tumor macroscopically or microscopically and no evidence of distant metastasis. Patients with metastatic disease who had undergone palliative resection were excluded. A doctor specialized in chemotherapy in our institution determined which patients received adjuvant therapy and the treatment protocols. The patients in this series did not receive neoadjuvant treatment.Postoperative mortality was defined as deaths within 30 days after the surgery. Surgical morbidity was defined as any complication that occurred in the 30-day postoperative period. The complications were classified according to the Clavien-Dindo classification. Clinicopathological data were obtained from a prospectively constructed medical database. Survival data were obtained from outpatient clinical visits, letter interviews or telephone interviews. Survival duration was calculated from the time of surgery to death or the last follow-up date.Statistical analysis was performed using The SPSS program version 13.0 for Windows . All categorical data were presented as rate and continuous data were expressed as mean ±standard deviation (SD). Survival was calculated using the Kaplan-Meier method. The statistical significance was assessed by the log-rank test. Factors that were deemed of potential importance on the univariate analysis (p<0.05) were included in the multivariate analysis by Cox regression. Hazard ratios (HR) with 95% confidence intervals (CI) were obtained as a measurement of association. P value <0.05 was considered statistically significant.Ninety four patients diagnosed as histological T4 gastric carcinoma and treated with curative resection were selected for this study. Clinicopathological features of the patients were summarized in 2 twice daily on days 1–14 and oxaliplatin 130 mg/m2 on day 1), 34 patients (36.2%) received FOLFOX chemotherapy  and 19 patients (20.2%) received SOX chemotherapy . The patients in this series did not receive neoadjuvant treatment.Thirty-nine patients were included in the stage T4a group and 55 cases in the stage T4b group, according to TNM classification. The median length of stay was 26 days . A total of 17 patients (18.1%) had postoperative complications. These complications were listed in The overall survival of 94 patients with curative resection (R0) was 56.4% at 1 year, 22.9% at 3 years and 13.8% at 5 years. However, for 38 patients undergoing noncurative resection (R1 or R2), the overall survival was 39.5% at 1 year, 7.9% at 3 years and 5.3% at 5 years. Therefore, curative resection had a statistically significant influence on survival  after gastrectomy ranged from 3.2 to 6.9%. The median length of stay was 26 days in our series. It was longer than other international series reported. This might be related to the Chinese medical system and health care delivery models. In china, community medical was underdeveloped. Before operation, patients needed to stay in hospital many days for treatment of basic diseases, like hypertension, diabetes mellitus, malnutrition, etc. On the other hand, without family doctors to provide follow-up treatment for patients, the discharge standard in China was stricter than other places. Therefore, the length of stay prolonged.In our series, the 1-, 3-, and 5-year overall survival was 56.4%, 22.9%, and 13.8% respectively. Overall survival was a complex issue that could be influenced by many factors. Kunisaki found curability, mall tumor diameter and numbers of lymph node metastases were prognostic factors and suggested that curative resection should be performed for T4 gastric cancer with relatively small tumors and few lymph node metastases. Lymph node metastasis was also reported as an important indicator of prognosis for T4 gastric cancer. For patients with T4 gastric cancer, lymph node metastasis was associated with poorer survival. Neoadjuvant chemotherapy or aggressive adjuvant chemotherapy after radical resection was strongly recommended for these patients.


Coxiella burnetii.Q fever is a zoonosis with reported outbreaks in rural areas, related to farms and farm animals. In the urban area, the source of infection is almost always unknown and can be related to windborne spread of Coxiella burnetii etiology in prolonged febrile syndrome. We want to point out that Q fever can become a real threat even in the urban area.Objective: To emphasize the importance of Coxiella and the confirmation was made by immunofluorescence assay (phase I and phase II antibodies).We made a retrospective analysis of Q fever cases treated in Matei Balş Institute between August 2011 and July 2014, insisting on the delay of diagnosis and treatment in these cases. The diagnosis was made using ELISA for IgM antibodies against Coxiella infection were: lungs (82.02%), liver (76.04%) and heart (6.74% - 2 cases of myocarditis and 4 cases of endocarditis). The most common clinical presentation was for acute febrile disease associated with: pneumonia and hepatitis – 55.05%, pneumonia only – 23.59%, hepatitis only – 14.06%, endocarditis plus pneumonia and hepatitis – 4.49%, myocarditis plus hepatitis – 2.24%. More than two SIRS criteria were found in 70.7%; a procalcitonin level >2 ng/mL was found in 18.66% of cases. The delay between the first sign of disease and the diagnosis varied between 2 and 60 days with a mean duration of 15.21 days. The mean delay until an active antimicrobial was administered was 8.03 days. Doxycycline was the most utilized antimicrobial – 84.26%. In 15.74% of cases, fluoroquinolones were administered. The mean duration of therapy in non-endocarditis patients was 15.5 days.Eighty-nine patients with a mean age of 49.7 year-old and a sex ratio M:F = 1.6:1 were included: 9 patients in 2011 (10.11%), 21 in 2012 (23.59%), 33 in 2013 (37.07%) and 26 in the first semester of 2014 (29.21%). An ascendant trend was observed. Almost all cases were registered in the warm season (from May to September) - 83.14%. In the urban area were recorded 84.26% cases. In only 5 cases, the patients were at risk of contamination. The organs affected during Coxiella burnetii infection should be considered in patients with prolonged fever of unknown etiology. The association between pneumonia and hepatitis in a case of prolonged febrile syndrome is highly suggestive for Q fever even though the patient lives in urban areas.


Purpose: The purpose of this case series is to describe the efficacy of the EX-PRESS shunt in uveitic glaucoma.Methods: This prospective case series sequentially recruited uveitic glaucoma subjects with intraocular pressure (IOP) > 21 mm Hg despite maximal topical antiglaucoma medications from July 2012 to July 2013 in Hong Kong. All subjects received a trabeculectomy with mitomycin C (MMC) and EX-PRESS shunt implantation. The primary outcome measures included preope-rative IOP and postoperative IOP on day 1, 1 week, 1 month, and every 3 months thereafter. The secondary outcome measures included postoperative complications and follow-up procedures, pre- and postoperative Snellen best corrected visual acuity and cup-disc ratio, as well as the number of antiglaucoma medication required.Results: In a case series of five subjects with uncontrolled uveitic glaucoma, two had inactive anterior uveitis, and three had active panuveitis. The mean preoperative IOP was 35.4 ± 12.6 mm Hg on 3.8 ± 0.5 antiglaucoma eye drops. The mean day 1, 1 week and 1 month IOP's were 6.6 ± 3.7 mm Hg, 7.2 ± 3.2 mm Hg, and 12.6 ± 8.2 mm Hg, respectively. One case required subconjunctival MMC injections postoperatively; two required conjunctival resuture for leakage; and two had early postoperative hypotony that resolved after oral prednisolone. At 6 months, the mean IOP was 13.2 ± 4.6 mm Hg. Four out of five subjects had IOP < 21 mm Hg without medication, and all had IOP < 21 mm Hg with antiglaucoma medication.Conclusion: The EX-PRESS shunt demonstrates good IOP control with a propensity for hypotony in the early postoperative period in this small uveitic glaucoma series.How to cite this article: Lee JWY, Chan JCH, Qing L, Lai JSM. Early Postoperative Results and Complications of using the EXPRESS Shunt in uncontrolled Uveitic Glaucoma: A Case Series of Preliminary Results. J Current Glau Prac 2014;8(1):20-24. Around 21% of adults have been reported to have intermediate IOP rise after topical dexamethasone use.7Glaucoma is a serious complication that can occur in 10 to 20% of uveitis and even a higher prevalence in cases of Fuchs heterochromic cyclitis, herpes, or sarcoidosis-related uveitis.8The treatment of IOP rise in uveitis is most commonly with topical or oral antiglaucoma medications, but the response to treatment is often variable ranging from 0 to 80% reductions. When maximal antiglaucoma medications fail to control IOP, fltration surgery is often required; although, the success rate in uveitic glaucoma is often poorer than that of primary glaucomas. The success rate of trabecu lectomy in uveitic glaucoma, without the use of adjunc tive anti metabolites, is only about 30% and slightly improved to 50% at 5 years with the use of 5-fluorouracil (5-FU).9 The EXPRESS does not require a sclerectomy or peripheral iridec-tomy; hence, there is less infammation and less risk of blockage of the inner window by fibrin, blood, or iris. The rate of postoperative hypotony (4% vs 32%) and choroidal effusion (8% vs 38%) is also significantly less with the EXPRESS than in traditional trabeculectomy.10The EX-PRESS glaucoma fltration device is a metallic implant that provides an artificial channel to drain the aqueous into the subconjunctival space and it is less invasive and more precise than the traditional trabecu lectomy. It provides a significantly lower IOP in the first 3 years postoperatively and less antiglaucoma medication requirements 5 years postoperatively compared to trabecu lectomy.While, the efficacy of the EX-PRESS has been established in the use of primary open angle glaucoma (POAG), its efficacy in uveitic glaucoma is less well studied. The purpose of this case series was to describe the efficacy of the EX-PRESS mini shunt device in uncontrolled uveitic glaucoma.This prospective case series adhered to the tenets of the Declaration of Helsinki. Informed patient consent and approval by the Institutional Review Board were obtained prior to study commencement. The authors declare no financial or proprietary interests. All subjects were recruited sequentially from the ophthalmology clinic of a tertiary university hospital, Queen Mary Hospital, in Hong Kong during July 2012 to July 2013. The inclusion criteria consis ted of consenting individuals with uncontrolled uveitic glau coma with IOP > 21 mm Hg despite maximal topical anti glaucoma medications. The exclusion criteria included: age < 18 years, those who were unable to consent, only eye, previous glaucoma surgery, or those with less than 6 months follow-up. The surgical procedure for EX-PRESS shunt implantation was as follows: Local anesthesia with Xylocaine gel 2% . Fornix-based conjunctiva opening. Application of mitomycin C (MMC) 0.4 mg/ml for 3 minutes followed by irrigation with balanced salt solution. A 4 × 4 mm partial thickness sclera fap. Paracentesis and anterior chamber reformation with a cohesive viscoelastic. Injection of the EX-PRESS shunt (50 mm) into the ‘blue-line' junction adjacent to the clear cornea with the aid of a 27-gauge needle. No sclerectomy and peripheral iridectomy was required. The sclera fap was closed with 10-O Nylon. The conjunctival wound was closed with 10-O Nylon or 8-O Vircyl in an interrupted suture manner.The primary outcome measures were preoperative IOP and postoperative IOP on day 1, 1 week, 1 month and every 3 months thereafter. The secondary outcome mea sures included postoperative complications and follow-up procedures, pre- and postoperative Snellen best corrected visual acuity (BCVA), and cup-disc ratio (CDR), as well as the number of antiglaucoma medication required.Descriptive analysis of IOP, number of complications and procedures, pre- and postoperative eye drops, and BCVA and CDR were presented. Means were expressed as mean ± standard deviation. Complete success was defined as IOP ≤ 21 mm Hg without antiglaucoma medication and partial success was defined as IOP ≤ 21 mm Hg with topical antiglaucoma medication.There were five patients recruited during the study period. All subjects were males, ethnic Chinese with a mean age of 48.4 ± 12.9 years. There were three right eyes and two left eyes. All subjects had uncontrolled uveitic glaucoma with IOP > 21 mm Hg despite maximum topical antiglaucoma eye drops and open angles on gonioscopy. The mean preoperative CDR was 0.6 ± 0.3.Two subjects had anterior uveitis and had no ocular infa mmation for 6 months prior to the EX-PRESS implantation. Three subjects with panuveitis had persistent infam-mation leading up to the EX-PRESS implantation and were on oral steroids or oral immunosuppressants (cyclosporine and azathioprine). Two of these three patients had a posterior vitrec tomy to clear up the vitritis and one required repeated intravitreal steroid injections prior the EX-PRESS implantation.The preoperative Snellen BCVA ranged from 0.1 to counting fingers (CFs). The mean number of preoperative antiglaucoma eye drops was 3.8 ± 0.5 and the three subjects with active panuveitis required oral acetazolamide 250 mg four times daily. The mean preoperative IOP was 35.4 ± 12.6 mm Hg with maximal medication. The mean day 1, 1 week, and 1 month IOP's were 6.6 ± 3.7 mm Hg, 7.2 ± 3.2 mm Hg, and 12.6 ± 8.2 mm Hg respectively .Postoperatively, one case required four subconjunctival MMC (0.02 mg in 0.1 ml) injections during the first month for early postoperative scarring as determined by prominent conjunctival vascular injection and a fattened bleb. Two cases required conjunctival resuture for conjunctival recession with leakage postoperatively. Two cases had early postoperative hypotony due to ciliary body shutdown that resolved within the first month after oral prednisolone of 30 mg daily (0.5 mg/kg/day) for 1 week with gradual tapering. Of these two cases, one developed a shallow anterior chamber with near iridocorneal touch requiring anterior chamber reformation with viscoelastics. This case was further complicated by choroidal detachment with residual hypotony maculopathy with a 6-month post operative BCVA of 0.1 (preoperative BCVA was CF) .At 3 months, the mean IOP was 11.4 ± 3.6 mm Hg. At 6 months, the mean IOP was 13.2 ± 4.6 mm Hg and the mean number of antiglaucoma medication was 0.8 ± 1.8. Four out of the five subjects had IOP < 21 mm Hg at 6 months without antiglaucoma medication (complete success) and all had IOP < 21 mm Hg with antiglaucoma medication . The mean BCVA and CDR at 6 months were 0.4 ± 0.3 and 0.6 ± 0.3, respectively.11 94% at 1 year for the Ahmed drainage device,12 and 91.7% at 2 years for the Baerveldt drainage device.13 In our small case series, the complete success of EX-PRESS shunt for uveitic glaucoma is 80% (4/5) at 6 months without medication, and the partial success is 100% (5/5) at 6 months with antiglaucoma medication. Our findings are in line with a study by Reyes et al,14 reporting a success of 86% with or without medication and 73% without medication at 10 months after EX-PRESS. However, the population in Reyes' study consisted of both primary and secondary glaucomas, including uveitic glaucoma, thus, their success is likely to be higher than for uveitic glaucoma alone.The management of glaucoma in uveitis poses considerable challenges. The success rate of using glaucoma drainage device in uveitic glaucoma is higher than in standard trabe-culectomy. The success rate for the Molteno drainage device has been reported to be 87% at 5 years,8 However, given the predisposition to ciliary body toxicity from the absorption of antimetabolites, the risk and benefit of which must be balanced. In our case series, one subject with signs of early bleb failure, including conjunctival injection and a fattened bleb, received four postoperative injections of subconjunctival MMC within the first month. The bleb was salvaged and he achieved a complete success at 6 months. As for the choice of MMC vs 5-FU, reports have shown similar efficacy between the two in terms of IOP control.17 The use of postoperative antimetabolite injections was avoided in our subjects with overfltration and ciliary body shutdown.The use of postoperative 5-FU injections was demonstrated to improve the success of trabeculectomy in uveitic glaucoma by 50%.18 and the use of intraoperative MMC can further exacerbate ciliary body toxicity. A history of posterior vitrectomy for vitritis also predisposes the eye to hypotony due to removal of the supporting vitreous. In our series, two cases had ciliary body shutdown with hypotony but both resolved within the first month after a short course of oral steroids. For the case that had a resultant hypotony maculopathy, he had a posterior vitrectomy within 1 month prior to the EX-PRESS implantation; his BCVA after the EX-PRESS procedure improved from his preoperative level. Kaburaki et al19 reported that the rate of hypotony following trabeculectomy for uveitic glaucoma was 28.3%; however, this rate was for long-standing ocular hypotony in a population of inactive uveitis at the time of surgery. Thus, a direct comparison cannot be made with our series that reports early hypotony.Postoperative hypotony is common in uveitic glaucoma because uveitis itself releases infammatory cytokines that are toxic to the ciliary body,In theory, it is best to wait until the intraocular infamma-tion is settled for months before glaucoma surgery for uveitic glaucoma but in reality, the IOP is commonly uncontrolled during active infammation and like in our series, three of the subjects had active panuveitis with uncontrolled IOP despite maximal topical and systemic anti glaucoma medications. Des pite implanting the EX-PRESS in the setting of active uveitis, all three subjects were able to achieve complete success at 6 months.vs 14.0 to 47.4% in traditional trabeculectomy.20 The rate of postoperative hypotony in uveitic glaucoma is expected to be higher like in our series, 40% (2/5), due to the possibility of ciliary body shutdown from both infammation and antimetabolite toxicity as well as after posterior vitrectomy for vitritis. Compared to the Ahmed valve that has a resistance to aqueous outfow, the rate of early postoperative hypotony is around 9% in those with uveitis from systemic disease.21 However, glaucoma drainage devices are associated with other complications like corneal decompensation, extraocular motility disorders, conjunctival thinning, and hypertensive phase that are seldom seen with the EX-PRESS. Cyclophotocoagulation is an alternative treatment modality but has a postoperative hypotony rate of 19% in uveitic glaucoma22 together with risks of increased infammation, retinal detachment and phthisical changes.The EX-PRESS shunt has been advocated to offer better early postoperative IOP stability and less hypotony due to a smaller lumen size (50 or 200 mm) versus the largely visible sclera window of a traditional trabeculectomy. The published early postoperative hypotony rates for EX-PRESS in POAG ranges from 4.0 to 47.2% Very few studies have reported the early postoperative results and complications of using the EX-PRESS shunt for uveitic glaucoma alone. The surgical approach to the management of uveitic glaucoma will vary depending on center and surgeon preference. Our single center, non comparative case series has reported the early postoperative outcomes and complications of using the EX-PRESS in a small sample of uveitic glaucomas. The EX-PRESS shunt can successfully normalize IOP in the majority of uveitic glaucoma subjects, although, there is a higher propensity for hypotony in the early postoperative period compared to other glaucoma drainage devices. Larger trials are warranted to establish the long-term efficacy of using the EX-PRESS for the treatment of uveitic glaucoma, as well as to compare its efficacy with traditional trabeculectomy and glaucoma drainage devices.


To analyze the clinicopathological profile of young patients (≤ 40 years) with oral SCC and correlate with a control group (≥ 50 years) by means of histopathological grading systems.14 young patients and 14 control patients were selected with similar clinical stage and tumor location. Demographic and clinical data were obtained from patient records and histological sections were evaluated according to four histopathological grading systems. Associations between categories of demographic and clinical data were performed through Chi-square test and Exact Fisher test. The survival analyzes were performed according to the Kaplan-Meier method.p=0.022), they had a higher incidence of local recurrence and regional metastasis (p=0.018) and lower disease-free survival in 5 years (p=0.069). There was no difference in 5-year overall survival among the studied groups. There was no difference in histological grading between studied groups according to the four used systems.The comparison between groups showed a greater association of treatment modalities in younger patients (This study showed that, despite tumors had similar histological grade and more therapeutic modalities were used in the young group, tumors in young patients had a higher incidence of recurrence/metastasis, showing tendency to a more aggressive behavior.Key words:Squamous cell carcinoma, tumors histological grading, young. Squamous cell carcinoma (SCC) originates in the stratified squamous epithelium and represents 90-95% of all malignant neoplasms in the oral cavity . This diet al.  and older patients (patients ≥ 50 years), the aggressive nature of squamous cell carcinoma in younger individuals is due to a higher pathologic grade of the tumor.All patients aged under 40 years old with primary intra-oral SCC treated at the Parana Western Union Hospital for Studies and Cancer Combat - Uopeccan and Cascavel Oncology Center - Ceonc from 1998 to 2013 were retrieved.Inclusion criteria were records with complete clinicopathological and demographic data, treatment based on surgery with or without adjuvant radiotherapy and/or chemotherapy and viability for analysis of tumor tissue embedded in paraffin blocks. The Research Ethics Committee of the Piracicaba Dental School, State University of Campinas, Protocol 100/2012 approved this study.The demographic data (age and gender), social habits , tumor location, TNM stage, surgical margins, lymph node involvement, recurrence, metastasis, treatment and the patient’s current status were obtained from medical records. The results were compared with a control group (age ≥ 50 years) selected in a paired form of treated patients files in the period in the same institutions and with similar clinicopathological features , Table 2- Histopathological analysis After the sample selection, new histological sections with 4 µm thick were obtained from the paraffin blocks corresponding to surgical specimens and stained with hematoxylin and eosin (HE). The slides were evaluated using an optical microscope according to four histopathologic grading systems: 1) World Health Organization System - WHO System, 2) Malignancy Invasive Margins Deep Grading System - MG system , 3) HistScoring was carried out simultaneously by two calibrated authors (ISC and ALCAR) until consensus was achieved. To determine the intra-observer degree of agreement, 30% (n = 34) of the samples were randomly selected and examined twice. The intra-observer Cohen’s kappa coefficients were 0.83 for WHO grading system, 0.86 for MG system, 0.84 for HR model, and 0.88 for BD model. All investigators were blinded to demographic and clinical data and outcomes.- Statistical analysisThe associations between the categories of demographic and clinical data, as well as diagnostic of histopathological grading systems of the tumors were performed using the Chi-square test for independence and Fisher exact test. The age data was evaluated for standard distribution using the Shapiro-Wilk normality test and homogeneity of variance by F test. As these assumptions were not accepted, the two age groups were compared using the non parametric Mann-Whitney. The analysis of overall survival and disease-free survival were performed according to the Kaplan-Meier method, comparing the two age classes through the Gehan’s Wilcoxon test. The significance level was 0.05. Analyses were performed in the statistical package Statistica 7.0 .p = 0.622), smoking habit (p = 0.543), alcohol consumption (p = 0.871) and tumor location (p = 0.511)  met the inclusion criteria. The mean age of these 14 patients was 36.21 years (± 3.89), ranging from 20 to 40 years. Most patients were male 12 (85.71%) and 2 (14.29%) were female. Regarding the social habits, 10 (71.43%) reported smoking and 7 (50%) alcohol consumption. The mean age of the control group patients was 63.14 years (± 8.62), ranging from 50 to 84 years. Most were male 11 (78.57%) and 3 (21.43%) were female. According to the habits, 8 (57.14%) reported tobacco and 6 (42.87%) alcohol consumption. Regarding the tumor location, 11 (78.57%) developed on the tongue and 3 (21.43%) on the floor of mouth in the group of young patients. In the control group, 9 (64.29%) occurred on the tongue, 4 (28.57%) on the floor of mouth and 1 (7.14%) on the palate. The comparison between groups of young patients and control patients showed no significant differences regarding gender (= 0.511) .p = 1.000), N stage (p = 0.766), M stage (p = 1.000) and clinical stage (p = 0.924)  were classified as early stages T1-T2 and 4 (28.58%) as advanced stage T3-T4. Regarding the stage N, 10 patients (71.73%) in each group had non-metastatic regional lymph nodes (N0). In the youth group, 2 patients (14.29%) were N1 and 2 (14.29%) were N2. In the control group, 3 patients (21.43%) were N1 and 1 patient (7.14%) was N2. For distant metastasis, in both groups all 14 patients (100%) were M0. Clinical staging in both groups showed that 9 patients (64.28%) were classified as stage I and II, and 5 patients (35.72%) as stages III and IV. The comparison between groups of young patients and control patients showed no difference in the T stage (= 0.924) .As for treatment performed in young patients, 4 (28.57%) underwent only surgery, 4 (28.57%) surgery associated with radiotherapy and 6 (42.86%) surgery associated with radiotherapy and chemotherapy. In control patients group, 7 (50%) were surgery and other 7 (50%) surgery associated with radiotherapy .The analysis of surgical margins showed that in 11 young patients (78.57%) the surgical margins were free and in 2 (14.29%) compromised. In one patient (7.14%) this information was not available. In all 14 control patients (100%) the surgical margins were free . Neck diIn the clinical follow-up after cancer treatment, 8 young patients (57.14%) presented recurrence/metastasis compared to only 2 control patients (14.29%). Of the young patients with recurrence/metastasis, in 2 (25%) was local, in 2 (25%) was in lymph node and in 4 (50%) was local and in lymph node. In the control group, 1 patient (7.14%) had local recurrence and 1 (7.14%) in lymph node . Comparip = 0.022) and younger patients had higher rate of recurrence/metastasis (p = 0.018). On the other hand, regarding the surgical margins, lymph node commitment and current status did not differ between the groups, with p values respectively (p = 0.186) (p = 0.254) and (p = 1.000)  .p = 0.069), where young patients had worse rate .The overall survival rate (OS) in 5 and 10 years in the young group was 64% and 48%, respectively. In the control group, the overall survival rate (OS) in 5 and 10 years was 78% and 19%, respectively. Disease-free survival rate (DFS) for young patients was 37% in 5 years and 10 years. For the control patients the DFS was 78% in 5 years and 18% in 10 years. Comparing the two groups through Gehan’s Wilcoxon test, it was observed tendency to statistical difference in 5 years DFS  as well or moderately differentiated and 1 (7.15%) as poorly differentiated. No significant associations were observed between the studied groups in the WHO grading system  .The MG grading system ranked all 14 tumors of young and control patients as low or intermediate risk. In the young patients 1 tumor was classified as low risk and 13 (92.86%) as intermediate risk. In the control group 3 tumors were classified as low risk and 11 as intermediate risk. There were no significant associations with this classification in the comparative analysis between the groups  .p = 0.002), free surgical margins (p = 0.002) and absence of regional recurrence (p = 0.017)  in the young group were classified as low or intermediate risk and 7 (50%) as high risk. In the control group 6 tumors (42.86%) were classified as low or intermediate risk and 8 (57.14) as high risk. When evaluating the relationship between the young and control groups, there were statistical differences in the variables clinical stage III/IV (= 0.017)  .The BD risk score was performed in 13 young patients and in 6 was classified as low or intermediate risk and in 7 as high risk. In the control group 8 tumors as low or intermediate risk and in 6 as high risk. No significant correlation was observed between clinical parameters and the BD risk score in the comparison between groups . Analyziet al.  were diagnosed at an early stage (I and II), different than the study Benevenuto et al.  in whichet al.  or by a % were diet al. (p = 0.022).The parameters used to plan the treatment of patients with SCC are mainly based on clinical staging of the disease. The main form of treatment of oral carcinoma is surgery, which is frequently combined with other modalities such as radiotherapy and chemotherapy particularly in more advanced cases . Monteroet al. , in a syet al. .Regarding recurrence and metastasis, Siriwardena et al.  observed  between young and control patients with tumors of similar location and clinical stage. However, even considering the limitation of the sample, it was noticed that younger patients had a higher rate of local recurrence, high rate of regional metastases and lower 5-year disease-free survival, despite of similar clinicopathological features and use of more therapeutic modalities.


Back pain is one of the most common health problems for which physicians are consulted, and it can considerably decrease the quality of life of patients during a great part of their lives.Our study was designed for assessing the improvement in the quality of life of patients undergoing lumbar discectomy for chronic low back pain.We included 148 patients with chronic low back pain in the analytic observational study. Using the 36-Item Short-Form Health Survey (SF-36), we evaluated the quality of life before and 6 and 12 months after lumbar discectomy.Physical and mental health scores of patients significantly improved after 6 and 12 months of lumbar discectomy. The mean improvement in physical health scores was significantly higher in female patients than in male patients. However, the improvement in mental health scores was not significantly difference between the 2 sexes and the educational and body mass index (BMI) groups.Lumbar discectomy improves both the physical and mental health subscale of the quality of life in patients with chronic disc herniation. Low back pain caused by acute disc herniation is a common disorder among patients in the age group of 20–40 years . Back paNowadays, researchers in Iran are focusing on the psychological aspects of therapeutic methods. To this end, we designed our study for assessing the improvement in quality of life of patients who underwent lumbar discectomy for chronic low back pain.This study was an analytic observational study that was performed by using the cross-sectional method. It was approved by the Baqiyatallah Medical University Ethical Board and was fully supported and funded by Baqiyatallah Medical University.Study samples included 148 patients with chronic low back pain (reported 3 months after disease onset). These patients had been referred to the neurosurgery ward of Baqiyatallah Hospital from January 2009 to May 2010. In this study, we considered variables such as age, sex, educational level, job, height, and weight. Moreover, we collected data on history of abortion, leg pain, back pain, smoking, trauma, pregnancy (including number of pregnancies), driving, sitting for long periods, and lifting heavy objects. Using this data, we evaluated the quality of life of patients before and 6 and 12 months after lumbar discectomy.We considered the quality of life after laminectomy as the outcome measure in our study. This outcome, i. e. , the patients’ HRQOL, was assessed by using the SF-36 questionnaire, which consists of 36 questions. Not only does this tool yield a total score but it also produces the 2 subscales of physical health (0–100) and mental health (0–100) A higher score suggests a better HRQOL. SF-36 has been previously validated in Iran  and has All data were entered into the computer via the Statistical Package for Social Science (SPSS) software version 14. 0 . The aim of our study was to evaluate the quality of life in patients with chronic low back pain. Paired sample t-test was used for evaluating the quality of life before and after lumbar discectomy. One sample t-test was used for comparing the improvement in mental and physical health scores  and the lowest improvement in mental and physical health scores  before and after lumbar discectomy. The mean improvement in mental and physical health scores was compared by using an independent sample t-test before and 6 and 12 months after lumbar discectomy on the basis of the patients’ sex, educational level (under diploma or higher), and body mass index (BMI) (under 25 and above that). Two-tailed significance level of 0. 05 was used to detect differences between variables.Generally, researchers have focused on the psychological aspect of therapeutic methods and have evaluated them using some variables such as the quality of life. We designed our study for assessing the improvement in quality of life of patients who underwent lumbar discectomy for chronic low back pain. 70 men (46. 6%) and 78 (53. 4%) women were included in our study. Of these patients, 56 (38. 1%) had military jobs, and 77 (53. 4%) had a diploma or higher educational level. Mean age of the patients was 44. 33 ± 11. 53 years. Mean height and weight were 165. 52 ± 11. 17 cm and 75. 21 ± 11. 47 kg, respectively. Mean BMI was 27. 62 ± 4. 39. The mean overall duration of pain between diagnosis and surgery was 34. 61 ± 54. 60 days, and mean duration of pain before diagnosis was 57. 07 ± 68. 50 days . An evaluation of the history of patients showed that 106 patients (72. 1%) had a history of lifting heavy objects, 101 (68. 7%) of sitting for long periods, 59 (40. 1%) of driving, 20 (13. 6%) of smoking, 75 (51%) of pregnancy, and 22 (15%) of abortion . The evaluation of the physical health scores of patients with chronic low back pain showed that the physical health score of patients significantly improved from 47. 46 ± 5. 13 before lumbar discectomy to 53. 43 ± 5. 11 after 6 months (P = 0. 000) and to 56. 21 ± 5. 48 after 12 months (P = 0. 000) of lumbar discectomy , 2.The evaluation of the mental health scores of patients with chronic low back pain showed that the mental health score of patients significantly improved from 38. 16 ± 5. 45 before lumbar discectomy to 42. 54 ± 4. 10 after 6 months (P = 0. 000) and to 43. 48 ± 4. 40 after 12 months (P = 0. 000) of lumbar discectomy.Comparative analysis showed that the mean improvement in the physical health score 6 months  and 12 months  after lumbar discectomy was significantly higher than the lowest improvement in physical health score. Moreover, the mean improvement in the mental health score 6 months  and 12 months  after lumbar discectomy was significantly higher than the lowest improvement in mental health score.The mean improvement in the physical health score of female patients (10. 79 ± 7. 14) was significantly higher than that in male patients ; the improvement in mental health scores of female patients (6. 29 ± 7. 40) and male patients (4. 26 ± 6. 73) showed no significant difference (P = 0. 080).The mean improvement in physical health score showed no significant difference in the 2 educational groups . The mean improvement in mental health score in the under diploma group (5. 66 ± 7. 45) and higher than diploma group (5. 01 ± 6. 87) showed no significant difference (P = 0. 590).Mean of physical health score improvement hadn’t significant difference between two BMI groups (under 25 and above that). . Moreover, the mean improvement in mental health scores of the 2 BMI groups under 25 (6. 25 ± 7. 27) and above 25 (4. 92 ± 7. 07) were not significantly different (P = 0. 310).We included 148 patients in our study. The physical and mental health scores of patients 6 and 12 months after lumbar discectomy were significantly higher than those before lumbar discectomy. Mental health improvement in men and women was not significantly different. The mean improvement in physical and mental health scores showed no significant differences between the 2 educational and BMI groups. Lumbar disc herniation is the most common disease caused by spinal degenerative processes and accounts for 30–80% of the low back pain cases . The intFor the complete assessment of benefits of a surgical intervention, it is essential to provide evidence of the influence over the patient in terms of the health status and HRQOL , 18. TheOur study had some limitations. First, we assessed the quality of life scores by using the SF-36 questionnaires; other methods may show different results. Second, the study was restricted to the Iranian population. Third, this study was conducted at a single center, and hence, the external generalizability of our findings to other countries or centers is uncertain. Lumbar discectomy improves both the physical and mental health subscale of the quality of life in patients with chronic disc herniation.


In the United Kingdom and Ireland more than 40% of individuals living with perinatally acquired HIV are now aged >16. Globally, increasing numbers of women with perinatally acquired HIV are becoming pregnant, but data on fertility and pregnancy outcomes is scarce. We present pregnancy outcome data for this emerging cohort.Pregnancies in diagnosed HIV-infected women in the United Kingdom and Ireland, and children diagnosed with HIV, are reported to the National Study of HIV in Pregnancy and Childhood. We analyzed data on pregnancies in women diagnosed aged ≤13 with perinatally acquired HIV, reported by June 2014.A total of 759 females born before 2001, diagnosed with perinatally acquired HIV aged ≤13 years, and in care in the UK and Ireland have been reported. Forty-four of these (6%) have had at least one pregnancy reported, with nineteen 2nd and four 3rd/4th pregnancies. Women's year of birth ranged from 1985 to 1996; 60% of women were UK/Irish-born and 39% African-born. Twenty one percent were diagnosed at <2 years, 39% at 2–7 and 41% at 8–13 years. Nine pregnancies were conceived in 2005–07, 22 in 2008–10 and 36 in 2011–13. Median age at conception of first pregnancy was 19 years. CD4 count was >500 cells/µL in 36% of first pregnancies, 350–499 in 15% and <350 in 49%. Women were on antiretroviral therapy (ART) at conception in 71% of pregnancies. There were 51 singleton live births, 2 miscarriages, 9 terminations and 5 continuing to term. In 17 live births to women not on ART at conception, median gestational age at start of ART was 17 weeks (range 3–29). HIV viral load was <50 copies/mL near delivery in 64% of live births, 51–1000 in 31% and >1000 in 5%. Forty four percent of live births were delivered by elective caesarean section (CS), 27% by emergency CS, 27% by planned vaginal delivery and with one unplanned vaginal delivery. Of 29 live births with viral load <50, 31% were delivered by elective CS, 17% by emergency CS and 52% by vaginal delivery. Fifteen percent of infants were delivered at 32–36 weeks gestation, and 2% at 30 weeks; 16% weighed 1.5–2.5 kg and 16% weighed <1.5 kg. Among 38 of the 51 infants where infection status is already reported, one is perinatally infected.Currently at least 6% of perinatally infected women in care in the UK and Ireland have experienced one or more pregnancies. Linking paediatric, pregnancy and second generation data will enable further monitoring of pregnancy outcomes in this newly emerging population.


In Africa and Asia hair dye is applied together with henna to decorate the hands and feet. Paraphenylene-diamine (PPD), a highly toxic constituent of hair dye can lead to acute kidney injury (AKI).A cohort study was conducted during the period from April 2012 to March 2013 in Khartoum Teaching Hospital, Sudan. It targeted adults presenting acutely with an evident history and clinical features of hair dye poisoning, together with AKI as per the RIFLE criteria. Analysis of data was done using SPSS.30 adults were included, their mean age was 25.6 ± 4.2 years, 93.3% were females. Exposure to PPD was suicidal in 86.7%. The mean duration to onset of renal symptoms was 34.8 ± 7.6 hours, maximum median serum creatinine was 8.6 ± 2.3 mg/dl, 86.7% had loss of kidney function as per the RIFLE classification and required dialysis. Initial renal recovery was seen after a mean duration of 9.8 ± 2.2 days. One patient died, 3.3%; all others, 96.7%, recovered normal kidney function. The amount of ingested PPD correlated significantly to the severity of symptoms, number of dialysis sessions required and time for renal recovery with P values < 0.05.Hair dye poisoning was associated with prolonged hospital stay, requirement of dialysis and increased morbidity. The severity of symptoms directly correlates to the dose of PPD ingested, with the kidney damage being reversible in almost all survivors. Lawsonia inermis). The combination, Black henna, is applied as a temporary tattoo to decorate the hands and feet in special social events such as wedding ceremonies [In Africa and Asia hair dye is applied by women as a cosmetic agent together with henna, leaves of a non-toxic herb . Descriptive analysis was done for all variables. Variables were expressed as percentages, means and / or medians with standard deviations. Comparison of data was done using the Student′s t test for continuous variables and Fisher′s exact XDuring the period from April 2012 to March 2013 a total of 30 adult Sudanese patients were admitted to Khartoum Teaching Hospital Emergency Department with hair dye poisoning and PPD induced AKI as per the inclusion / exclusion criteria set. All patients were using the same commercial brand of hair dye. The mean age of the study population was 25.6 ± 4.2 years, the majority were females, 93.3%, two-third of patients were having a secondary high school education level, 60% were unmarried, 43.3% unemployed and 26.7% were housewives. Exposure to PPD was via the oral route in all patients, 100%. Reasons for ingestion were a suicidal attempt in 86.7%, accidental in 10% and a suspected homicide in 3.3% .The mean duration from time of exposure to the appearance of renal symptoms was 34.8 ± 7.6 hours; these were mostly in the form of reduced urine output and the passage of dark chocolate brown urine seen in 90% and 76.7% of patients, respectively. Angioneurotic edema was seen in 53.3% of patients with emergency tracheostomy being done in all of them. All patients had normal echocardiographic studies despite that cardiac arrhythmias were documented in 40%.As per the AKI RIFLE classification most patients, 86.7%, had loss of kidney function and required dialysis therapy. In 73.3% of patients serum creatinine peaked to more than 10 mg/dl, with the maximum median serum creatinine for all patients being 8.6 ± 2.3 mg/dl. Dialysis replacement therapy was indicated in 86.7%, with only 13.3% of patients being treated conservatively. Indications for dialysis were mostly oliguria with rising blood urea of more than 200 mg/dl, uremic encephalopathy and pulmonary edema in 63.3%, 13.3% and 10% of patients, respectively. The average number of hemodialysis sessions required was 5 ± 1 sessions. Intradialytic complications in the form of hypotension and hypoglycemia were evident in 10%. Initial signs of renal recovery were seen after a mean duration of 9.8 ± 2.2 days. Overall, 96.7% of patients recovered normal kidney function, whereas 3.3% died. None of the study patients developed end-stage renal disease .Among the study group the dose of PPD ingested correlated significantly to the severity of symptoms in the form of occurrence of pulmonary edema, cardiac arrhythmias, high serum creatinine levels at presentation, requirement of dialysis therapy, number of dialysis sessions required and duration to onset of renal recovery; P values being less than 0.05 . FurtherHair dye poisoning had been repeatedly reported as an important cause of suicide and para-suicide, with various case series being described from East Africa, the Middle East and the Indian subcontinent , 15–19. Hair dyes contain PPD at various concentrations ranging from 0.2% to 3.75%. It is PPD, the toxic ingredient causing laryngeal edema, rhabdomyolysis, severe metabolic acidosis and AKI following hair dye poisoning . All patRenal involvement post hair dye poisoning can be transient and pass unnoticed; again it can be severe enough to necessitate dialysis , 21. In Hair dye poisoning had been widely reported in Sudan with the majority of patients being young females. Most of those who develop developed AKI require dialysis. The condition is associated with multisystem involvement, prolonged hospital stay, requirement of dialysis therapy, increased morbidity and a high risk of death due to angioneurotic edema and cardiac arrhythmias. The severity of symptoms was directly related to the dose of PPD ingested.


The considerable height of drug allergy is presently marked and local anesthetics are one of its frequent causes. Lately Articainum and his analogues is most widely used. Articainum is local anesthetic of group of amides, having instead of benzol circle of tiophene and additional aethereal group. In medicine composition auxiliary substances including epinephrine are used. Allergic reactions to it meet less often than to Novocain, however they are possible. There are several analogues of articainum on the market.To define the features of hypersensitivity on local anesthetics based on Articainum of different firms-producers.The investigation exposed to 492 patients. These patients with complicated allergic anamnesis were sent by dentists to realization of allergy tests in vitro for few preparations including a few analogues of Articainum. Age of patients was 2 -- 81 yrs, averaging 25.0 ± 1.6. yrs. (61.2% women). The representatives of articainum  were used. In dough in vitro was put 1035 tests (not counting controls), up to 4 for a patient, on the average there was 2.10 tests for a patient. 447 tests appeared positive result (43.2%). Drug cytotoxic test (the Rate of neutrophils' damage) was used.At testing of Articainum® it was determined 16 tests positive from 247 (6.5 ± 2.2%), for Ultracainum® -- 13/227 (5.7 ± 2.1%). Ubistezinum® and Ubistezinum® forte 70/332 (21.1 ± 3.6%) and from 61/229 (20.4 + 3.6%), respectively. Thus, four basic representatives of local anesthetics gave different indexes, divided into 2 groups - with the low and moderate level of sensitization. The educed distinctions between groups were reliable (ð<0.01). For further treatment "negative" local anestetics were applicated. No allergic reactions were registered.1. Drug cytotoxic test showed well applicability for prevention of drug hypersensitivity for local anesthetics. 2. Thus, local anesthetics based on articainum and produced by different providers have shown considerable difference on the profile of safety concerning drug allergy. There is an evidence of greater safety of Articainum® and Ultracainum®. 3. It confirms a thesis about dependence of drug allergy not only on a basic substance but also from other descriptions -- concentration, type of auxiliary substances, etc. 4. The importance of the testing of exactly that preparation that is planned to the further use is proven.


An effective fluid challenge should increase the mean systemic filling pressure (Pmsf ) in order to increase the venous return. The objective of this study was to determine the minimum volume of intravenous fluid required to significantly increase the Pmsf.P < 0.05.Patients following cardiac surgery were randomly allocated to receive 1, 2, 3 or 4 ml/kg (body weight) of crystalloid over 5 minutes using a 60 ml syringe. Pmsf was measured using the arterial pressure after stopping blood flow in the arm with a pneumatic tourniquet inflated for 1 minute. Cardiac output (CO) was also recorded at baseline and immediately after the fluid infusion. CO was measured with LiDCO or pulmonary artery catheter, and a positive response was considered an increase of 10% from baseline. From previous data, the least significant change for Pmsf was 15%. Medians were compared using the independent samples media test, and proportions were compared using a chi-square test. Statistical significance was considered when R2 = 0.28, F(1.47) = 17.8, P < 0.001). The predicted dose of fluids required to achieve a change in Pmsf of 15% is 3.7 ml/kg crystalloids.Fifty patients were included, 40.8% of them were responders. The proportion of responders increases with the increase of dose of fluids Table . The regThe minimum volume required to perform an effective fluid challenge is 4 ml/kg infused in 5 minutes. However, only 30% of the variation of change in Pmsf can be explained by the dose of i.v. fluid given. The proportion of responders increases with the volume of fluids.


High recall rates from surveillance breast MRI are associated with patient anxiety and increased workload. NHSBSP guidelines recommend a maximum of a 10% recall rate with an expected rate of <7% in high-risk women undergoing surveillance with breast MRI. Our aims were to review surveillance breast MRIs performed at our institution from 2009 to 2013 to determine the recall rate and cancer detection rates.Surveillance MRIs performed in women at high risk of developing breast cancer over a 5-year period were reviewed. Breast MRI was performed using a standard protocol on a 1.5 Tesla MRI. For all patients with a BIRADS MRI 0, 3, 4 or 5 score, additional imaging, modality of biopsy and histology were recorded.A total of 1,119 surveillance breast MRIs were performed over the 5-year period. These included women with a known genetic mutation or those at high risk based on genetic assessment. In total, 121 (10.8%) had BIRADS MRI scores which required recall for further imaging. Seventy-one patients (58.6%) had a biopsy performed and 19 cancers were detected, giving an overall cancer detection rate of 1.7%. Eleven (9%) were invasive ductal tumours. Of those recalled, 74 (61%) were in the prevalent round of screening.While our data compare favourably with published data, the breast MRI recall rate is greater than the expected 7% recommended in the UK. This may be due to large numbers in the prevalent round.


Mycobacterium avium subsp. hominissuis, isolated from cases of lymphadenopathy in swine and humans, differing in virulence in a murine intranasal infection model.This paper announces the genome sequences of four strains of  Mycobacterium avium complex are the most frequently isolated from patients , bacteria of the patients , 2. The inissuis . These sterioses , and an escribed . As M. a cluster , we idenand 2013 .Using an intranasal infection model in BALB/c mice we compared the virulence of porcine and human isolates with different MST types . Bacterial replication was monitored for 3 months by plating lung, spleen, and liver homogenates on Middlebrook 7H11 agar. Isolates varied significantly in virulence, with a human (12_062) and a porcine (LYM122) isolate of MST type 22 clearly showing higher bacterial numbers in lungs and more dissemination to spleen and liver than a human (12 _067) isolate and a porcine (LYM086) isolate of MST type 91.Whole-genome sequencing was performed on these four isolates with an Illumina MiSeq (2 × 150-bp), and a quality analysis was realized using FastQC version 0.11.5. Assembly of the sequences in contigs was performed using Velvet version 1.2.1 and VelvetOptimiser.pl version 2.2.5. MyRast software was enabled to identify open reading frame regions, which were annotated using the database FigFams. Genome statistics are given in The four genome sequences have been deposited at the European Nucleotide Archive under the accession numbers listed in


This study was aimed at establishing the effect of sputum quantity in the pick-up rate of AFB microscopy by comparing sputum samples of 5.0 mL and 2.0 mL.Optimum sputum results for acid-fast An analytical cross-sectional study was carried out at the Dr George Mukhari Hospital (DGMH) in Pretoria, South Africa, from 05 January 2007 to 04 January 2008. Two sputum samples, 5.0 mL and 2.0 mL, were collected from each of the 330 adult PTB (pulmonary tuberculosis) suspects. Fluorescence microscopy was used in the sputum analysis. The yield through microscopy of the 2.0 mL specimen versus the 5.0 mL specimen was compared and analysed, using culture results as the gold standard.PV+) 98.3% (95% CI 91.1% – 99.7%), negative predictive value (PV-) 93.3% (95% CI 89.7% – 95.7%), the likelihood ratio (LR) for a positive microscopy 192 and the LR for a negative test was 0.23. In the 2.0 mL specimens, the sensitivity was 75.3% (95% CI 64.6% – 83.6%), specificity 99.2% (95% CI 97.1% – 99.8%), positive predictive value (PV+) 96.7% (95% CI 88.6% – 99.1%), negative predictive value (PV-) 93.0% (95% CI 89.3% – 95.4%), the LR for a positive microscopy was 94 and 0.25 for a negative microscopy. There was a statistically significant association  between the microscopy and culture tests in both the 5.0 mL and the 2.0 mL specimen categories. The strength of association between the microscopy and culture, as indicated by the kappa test was 0.83 and 0.81 in the 5.0 mL and 2.0 mL categories, respectively.From a sample of 330 specimens, 77 tested AFB positive on microscopy. In the 5.0 mL samples, the sensitivity was 76.6% , specificity 99.6% (95% CI 97.8% – 99.9%), positive predictive value (Compared to the 2.0 mL specimen category, the yield for AFB microscopy in the 5.0 mL specimen category was consistently superior, as indicated by the higher sensitivity, specificity, predictive values and the likelihood ratios in the 5.0 mL specimen category. It is recommended that sputum specimen collection for AFB microscopy should aim for a minimum volume of 5.0 mL. Prompt diagnosis of TB plays a pivotal role in therapy outcome. However, some cases suspected of pulmonary tuberculosis on clinical grounds, are not confirmed bacteriologically because of a patient having a dry cough or inadequate sputum (< 2.0 mL). This results in false negative sputa in about 25% – 50% of cases of pulmonary tuberculosis.8 In this regard, the study became necessary because, at the time of the study, the Level One wards at the hospital did not have a policy relating to a recommended sputum quantity. We conducted this study to compare the yield of a 5.0 mL versus a 2.0 mL specimen.Adequate sputum is required for a diagnostic yield in AFB detection. Researchers have suggested the use of 5.0 mL as adequate sputum for AFB detection in the diagnosis of PTB (Pulmonary tuberculosis).Ethical clearance to conduct the study was obtained from the Medunsa Research Ethics Committee (MREC) of the University of Limpopo (Clearance Certificate Number: MREC/M/50/2009).From 05 January 2007 to 04 January 2008, a cross-sectional descriptive study was conducted at the Dr George Mukhari Hospital, Pretoria, to determine if the volume of sputum affects AFB microscopy yield. Each patient was requested to cough up two sputum samples at least 2 hours apart in the early morning. There is no consensus or evidence on the acceptable time lag (e.g. 2 hours versus 24 hours apart) between sputum sample collections for a better yield in sputum smear microscopy. The research assistant (a nurse) supervised the sputum collection. Each patient was requested to cough up sputum into the specimen bottle until the sputum quantity reached the labelled mark on the bottle, 2.0 mL or 5.0 mL. When necessary, a patient was requested to cough up additional sputum to fill up the specimen bottle to the required mark. On an alternating basis, one patient was requested to start filling up the 5.0 mL green-labelled specimen bottle, followed by the 2.0 mL red-labelled specimen bottle at least 2 hours apart. The next patient was requested to reverse the order, starting with the 2.0 mL, then the 5.0 mL specimen bottle. This was done to ensure an even distribution in the order of sputum quantity collection to minimise a sputum collection bias.9 During the period of data collection, sputum samples were collected randomly from TB suspects willing to participate in the study. Clinical suspicion of TB in patients was based on at least three of the following criteria:a persistent cough for a period longer than 2 weeksnight sweatsfeverloss of appetiteweight-lossmalaisechest painshortness of breatha positive history of contact with an infectious TB patient.The number of PTB suspects per annum seen at DGMH  in 2007 was 2348.Consenting patients provided sputa in sterile containers at room temperature.Only patients above the age of 18 who consented to participate were included in the study. Using the SPSS 17.0 for Windows computer software, the representative sample size computed at 95% confidence level and 5% confidence interval (CI), was 330 patients. Randomisation was achieved by selecting every seventh PTB suspect admitted to Level One wards for inclusion in the study. If a particular patient declined participation, the next consenting patient was included, to be followed by another seventh patient. Patients too ill to participate were excluded from the study.auramine staining and fluorescence microscopy as previously described.10Two sputum samples, one of 5.0 mL and the other of 2.0 mL, were collected from each adult PTB suspect. Patients were advised on how to enhance sputum expectoration. Sputum samples were then taken to the laboratory within 2 hours of collection. The sputum was analysed with the aid of Recruited patients were educated on the importance of producing a good sputum sample  and it was explained to them that two specimens with different quantities were required. The patient was then shown and instructed on how to enhance sputum expectoration. Sputum collection took place in an open area under direct supervision of one of the researchers to prevent infection of the researchers and other patients.This following section does not describe data collection but specimen collection and laboratory methods.The patient was given two sterile sputum containers, one labelled with a green marker and the other labelled with a red marker. The green-labelled container was for the collection of 5.0 mL sputum whilst the red-labelled container was for 2.0 mL sputum. The level of the volume required was clearly marked on each specimen container to guide patients as to the sputum quantity required. Both the 2.0 mL and the 5.0 mL sputum containers were subsequently sent for microscopy and culture. Each specimen was given a different laboratory number and all specimens were thus treated separately as though they were from different patients. Consequently, two laboratory analysis requisition forms were completed for each patient. Each specimen and attached requisition form were put into specimen plastics, sealed and immediately taken to the laboratory. If there was an anticipated delay of more than 2 hours in transporting the specimen to the laboratory, the specimen was stored in a refrigerator at 4 °C.Only sputum samples collected on the first morning were used in the study. Sputum samples collected on subsequent mornings or days, as required by the national tuberculosis programme for diagnosis, were not included in the study. The culture was grown according to standard procedures by the National Health Laboratory Services (NHLS) of South Africa, using the Mycobacteria Growth Indicator Tube 7 mL (MGIT) method. Culture tubes were entered into the BACTEC MGIT instrument and continuously incubated at 37 °C and monitored every 60 minutes for increasing fluorescence. Analysis of the fluorescence was used to determine if the tube was instrument-positive, that is, if the test sample contained viable organisms. Culture tubes which remained negative for a minimum of 42 days were regarded as negative.p-value was determined whilst kappa was used to measure the strength of agreement. The sensitivity, specificity, positive and negative predictive values, and likelihood ratios for a positive and negative microscopy results of sputum samples were calculated to determine the relationship between AFB microscopy and culture tests.The statistical software mentioned above was used for data entry and analysis. Descriptive statistics, frequencies and percentages were calculated. Two-by-two tables were drawn to determine the relationship between the 5.0 mL and 2.0 mL specimens as compared to the culture which was the gold standard test. For statistical significance, the The majority of the patients, 110 (32.1%), were aged 18–29, 95 (28.8%) were aged 30–40, 68 (20.6%) were 41–51 years old, 38 (11.5%) were aged 52–62, 21 (6.4%) were 63–73 years old and 2 (0.6%) were aged 74–94.Of the 330 patients, 146 (44.2%) were male and 184 (55.8%) were female. The prevalence of AFB positive sputum results in the 2.0 mL samples was 17.6% (58/330) and 17.9% (59/330) in the 5.0 mL samples.Sixty patients (18.2%) were positive and 270 (81.8%) were negative for the AFB test in the 5.0 mL category, whilst 58 (17.6%) were positive and 272 (82.4%) were negative for the AFB test in the 2.0 mL category. The gold standard AFB culture results revealed 77 (23.3%) as positive and 53 (76.7%) as negative sputa.PV+) was 98.3% (59/60), (95% CI 91.1% – 99.7%) whilst the negative predictive value (PV-) was 93.3% (252/270), (95% CI 89.7% – 95.7%). The likelihood ratio (LR) for a positive microscopy in the 5.0 mL volume sputa was 192 [76.6 ÷ (100 - 99.6)], whilst the LR for a negative test was 0.23 [(100 - 76.6) ÷ 99.6].In the 5.0 mL sputum samples, out of the total of 77 specimens that were positive according to the gold standard culture test, 59 tested positive on AFB microscopy, resulting in a sensitivity of 76.6% (59/77), (95% CI 66.0% – 84.7%), . MeanwhiPV+) was 96.7% (58/60), (95% CI 88.6% – 99.1%) whilst the negative predictive value (PV-) was 93.0% (251/270), (95% CI 89.3% – 95.4%). The likelihood ration (LR) for a positive microscopy in the 2.0 mL specimens was 94 [75.3 ÷ (100 - 99.2)], whilst the LR for a negative microscopy was 0.25 [(100 - 75.3) ÷ 99.2].The 5.0 mL sputum smear test gave false negative results in 23.4% (18/77), (95% CI 15.3% – 34.0%) patients whilst the 2.0 mL sputum smear test gave a false negative value of 24.7% (19/77), (95% CI 16.4% – 35.4%). There were 0.4% (1/253), (95% CI 0.07% – 2.2%) false positive results encountered for 5.0 mL and 0.8% (2/253), (95% CI 0.2% – 2.8%) for the 2.0 mL sample.11 We were focussing on PTB suspects on clinical grounds, hence a wider scope, whereas their focus was mainly on radiological changes. The fact that TB suspects are in the young adulthood age-group (hence breadwinners), has economic implications for the society. This places the onus on the clinician to properly diagnose each TB suspect by using the sputum quantity with a better yield, to enable early therapeutic intervention.The majority of the patients (60.9%) were between the ages of 18 and 40 years, of whom 53.7% were 18–29 years old. The incidence in the 18–40 age group in this study was slightly higher than a similar study conducted in Mexico (52%).12 Matee et al., in a study conducted in the Muhimbili University in Dar es Salaam, Tanzania, sought to determine the diagnostic accuracy of sputum microscopy for active case findings of HIV-associated PTB using TB culture as the reference standard. No mention is made of the quantity of sputum used. However, their overall sensitivity and specificity of sputum microscopy was 61.8% and 99.7%, respectively,13 which were lower than found in this study. This could be ascribable to the relatively smaller sample of culture positive sputum results in this study compared to their sample (77 versus 212).The prevalence rate of the AFB positive sputa by microscopy was virtually similar in the 5.0 mL versus the 2.0 mL sputum specimens . The smear sensitivity rate of 76.6% obtained using the 5.0 mL sputum specimen, and 75.3% obtained using the 2.0 mL specimen, from patients suspected of having TB in this study, was in keeping with the upper limit of the range of sensitivity for smear microscopy reported by Foulds and O'Brien to vary from 30% to more than 70%.Mycobacterium tuberculosis (MTB), thus accelerating treatment of TB. In the first period, the acid-fast staining was carried out using sputum specimens regardless of volume. In that way, a sensitivity of 72.5% was obtained, compared to 92.0% for sputum specimens of volumes ≥ 5.0 mL during the second period.14 The better yield of the sputum specimens with the minimum of 5.0 mL tallied with our study even though the methodologies used in the two studies differed. The relatively low sensitivity in our study could be attributable to the comparatively smaller sample size and the high prevalence of HIV seropositive patients (65.2%) in our Level One wards, because there is an association between decreased host immunity and reduced sputum smear positivity leading to an increase in false negative smears.15In a study conducted by Warren et al. over two periods, 1992–1993 and 1996–1999, the yield using a minimum of 5.0 mL sputum specimen for AFB diagnosis was found to increase sensitivity for 16In contrast with the likelihood ratio for a negative microscopy test that was almost similar in both the 5.0 mL and 2.0 mL sputum samples, the likelihood ratio for a positive microscopy in the 5.0 mL sample was almost double that in the 2.0 mL samples , clearly in favour of the 5.0 mL sputum sample for AFB microscopy. Clinically, this finding indicates that by using a 5.0 mL specimen, the probability of finding a false positive in a truly negative result is almost 50% lower than by using the 2.0 mL specimen. This finding was corroborated by the relatively higher positive and negative predictive values in the 5.0 mL specimen category, compared to the 2.0 mL category. The difference is of clinical importance because the diagnostic value of a test depends on its positive and negative predictive values, which vary with the prevalence of the disease in a given community.17 The false negative results were slightly lower in the 5.0 mL specimens compared to the 2.0 mL specimens . Furthermore, the false positive results in the 5.0 mL specimens were 50% lower than those in the 2.0 mL samples . An increase in false positive results reduces the specificity of a test by increasing the denominator of specificity.18 The clinical implication of an increase in false positives is the over-diagnosis of a condition with unnecessary commitment of resources on subjects who do not need the resources.As mentioned above, the smear microscopy used in this study was based on fluorescence microscopy of concentrated sputum sediments following centrifugation and is commonly considered to have superior sensitivity compared with conventional light microscopy.14 Therefore, the best use of limited resources for the detection of smear-positive PTB cases would be to improve the quality of self-expectorated sputum collection and microscopy. Only supervised sputum collection was used in our study, we did not use augmented and invasive sputum collection techniques as recommended in other studies.20 However, PTB suspects who are unable to produce sputum, should be followed-up regularly or even admitted to a health-care facility if possible. The inability to produce sputum is common in immunocompromised patients.21 There was a high prevalence of sero-positive patients in our Level One wards which led the researchers to the conclusion that every effort should be attempted to obtain adequate sputum from every suspected PTB sufferer. To enhance sputum collection, various methods are available, from sputum induction and physiotherapy, to more invasive procedures like bronchoalveolar lavage.22Supervised sputum collection by a health care professional during sputum collection is an important factor in obtaining quality sputum samples. Improving sputum quality has been shown to improve the yield of sputum microscopy.18 Sputum collection should be done preferably in the early morning, in a secluded and well ventilated environment so that it does not pose a threat of infection to others. Supervised sputum collection combined with patient instruction, is of great value in obtaining a good quality sputum specimen , as demonstrated by Sakundarno et al. in a study to determine factors associated with insufficient quality of sputum collected for PTB diagnosis in Indonesia.23 They deduced that, in their district, only a few PTB suspects (45%) provided samples of good colour, viscosity and volume (3.0 mL). One of the reasons identified for this result was poor patient education by health care workers on how to collect sputum. In our study patients were guided on the correct way to provide sputum.It has been established from the literature that patient education, allied health worker training and involvement of the community are also of value in a TB programme.25 It has also been shown that there is always the element of specimen container contamination in the wards which could lead to specimen contamination before the specimen reaches the laboratory.27 Nevertheless, in spite of the precautions, 8.5% of the specimens in our study tested positive for mycobacteria other than tuberculosis (MOTT) by culture.Sputum samples that were collected for this study were kept less than 1 hour after collection (en route to the laboratory), to avoid contamination with other micro-organisms from possible excessive specimen handling in the ward. Studies have shown that sputum specimens for AFB detection could be preserved safely in the refrigerator (4 °C) for up to 8 weeks without affecting the sputum-smear positivity result.bacilli in a specific field as well as the level of expertise of the microscopist. Comparing direct sputum microscopy and the NALC-NaOH (N-acetyl-L-cysteine-sodium hydroxide) method, Farnia et al. established that the NSLC-NaOH method was more reliable. They found the sensitivity and specificity of NALC-NaOH method to be 83% and 97% respectively, which was higher than that of direct sputum microscopy which stood respectively at 46% and 90%.28 The NALC-NaOH method was used in this study. This method, however, is not performed in countries with limited resources. Errors by the microscopists in examining sputum smear slides could also have affected our study results, thereby increasing the number of false negative smears. A study has shown that implementation of proficiency testing of microscopists and the introduction of a rechecking system for external quality assurance could help in evaluating diagnosis.29 The process is labour intensive, however, especially in countries with a high TB burden. The limitation of this study was the relatively small sample size.Direct microscopy results tend to display variability depending on the microscopic field used, and the number of This study has indicated a tendency towards superiority in the AFB microscopy results yield of the 5.0 mL specimen category compared to the 2.0 mL category as indicated by the relatively higher sensitivity, specificity and predictive values. With regard to the likelihood ratio (LR), given a positive microscopy with a 5.0 mL specimen, the ratio of a truly positive to a truly negative ratio is 192:1, that is, it is 192 times more likely to be truly positive than truly negative. With a 2.0 mL specimen, the LR is 94:1. Therefore with a 5.0 mL specimen there is a greater chance (more than twice better) of finding a truly positive result. From this point of view, the 5.0 mL specimen is to be recommended.


There is noconsensus on effect of serum progesterone level on the day of human chorionic gonadotropin (hCG)injection. This study aims to evaluate the effect of plasma levels of progesterone on the day of hCGinjection on the rate of pregnancy in A stratified cohort study was conducted over a period of one year (2009)on 38 infertile women with PCOS who were suitable candidates for the IVF program. Patients wereevaluated for other causes of infertility with hysterosalpingography (HSG), laparoscopy and normalsperm analysis. Patients were placed on the long protocol, followed by oocyte pick up, and finallyIVF-embryo transfer (ET). Study patients were grouped according to progesterone levels of greateror less than 1.2 ng/ml on the day of hCG injection. Pregnancy rates were defined in each group.Levels on day of hCG day clinical pregnancy outcome were assessed. Experimental data were thencompared against Fisher’s exact test in SPSS version 18.The overall pregnancy rate in this study was 26.3%. In the group with progesterone levelsmore than 1.2 ng/ml on the day of hCG injection, the clinical pregnancy rate was 4 (21.1%) andchemical pregnancy rate was 3(15.8%). In the group with progesterone levels less than 1.2 ng/ml,the clinical pregnancy rate was 1(5.3%) and chemical pregnancy rate was 2(10. 5%).This study showed that PCOS patients with progesterone levels more than 1.2 ng/mlon the day of hCG injection resulted in higher chemical and clinical pregnancy rates. However, nosignificant statistical differences were found between the two groups. For further verification, werecommend additional studies with larger numbers of subjects. Clomiphon (IVF) . Most ofon (IVF) . Thus, ton (IVF) , others on (IVF) ,6 did noon (IVF)  showed tThis stratified cohort study was conducted over a period of one year (2009) on 38 infertile women with PCOS who were suitable candidates for the IVF program. All cases were between ages 20 to 38 years. Patients were evaluated for other causes of infertility by hysterosalpingography (HSG) and laparoscopy. Their partners' sperm analyses, according to WHO guidelines (2002) were all normal. The criteria for selection of PCOS patients were based on: i. history of amenorrhea or oligomenorrhea; ii. hyperandrogenism  >2; and iv. increased ovarian volume >9 ml or antral follicle count ≥10 as seen with ultrasound.All patients underwent the long pituitary down regulation protocol. They were given low doses of oral contraceptives (OCP) on the third day of menstruation. On days 20 to 21 of their menstrual cycles , a GnRH agonist  at 500 ìg/day, sub-cutaneous injection was begun.After two weeks of Suprefact injections, on the third day of the next menstrual cycle, serum estradiol levels were checked and a vaginal sonographic scan was performed to confirm pituitary suppression. Induction ovulation was started in cases where: i. serum estradiol levels were <50 pg/ml, ii. there was no cyst or follicle >10 mm, and iii. the endometrial thickness was <4 mm. Otherwise, GnRH agonist would be given for an extra week, for up to 21 days. On the third day of menstruation, 150-225 units of gonadotropin[rFSH ] was administered according to age, weight, and FSH levels. Suprefact was decreased to half of its initial dose on that day. After administrating gonal-F for 5 days, ovarian response was monitored by vaginal ultrasound; then gonal-F was regulated. When there were at least two 18 mm follicles, hCG  at a dose of 10000 IU was injected. The progesterone level was checked on the day of hCG injection. Oocyte pickup was performed 36-38 hours later. After a period of 48 hours, embryo transfer with a Cook catheter (Cook catheter OB/GYN spencer JN) was performed. There were between 2-4 embryos that were transferred, dependent upon the embryo age and quality. Luteal phase support was carried out by progesterone injection, 100 mg per day from the oocyte retrieval day.Subjects were selected through interviews, examinations, and lab tests. Upon receiving information, all subjects consented to participate in the study. According to serum progesterone levels on the day of hCG injection, patients were divided into 2 groups of: i. <1.2 ng/ml or ii. >1.2 ng/ml. Clinical pregnancy was defined as detection of the fetal heart by ultrasound at 6-8 weeks gestation Chemical pregnancy was defined as ß hCG levels >200 IU. The rate of pregnancy was compared between the two groups. The experimental data were then compared against Fisher’s exact test . The level of significance was considered based on the criteria of p<0.05. This survey was conducted as an obstetrics and gynecology educational thesis at Tehran University of Medical Sciences and patients incurred no charges.A total of 38 PCOS patients participated in this study. Of these, 30 (78.9%) had primary infertility. The mean infertility duration was 8.7 ± 3.5 years and mean age of the patients was 34.7 ± 4.5 years. Mean basal serum FSH level was 7.4 ± 2.6 mIU/ mL and E2 level was 59.2 ± 30.8 pg/mL.The mean total dosage of gonadotropin used was 1950.8 ± 500.0 IU mean duration of induction was 13.1 ± 2.2 days. The mean number of oocytes was 10.4 ± 2.2 and mean total number of embryos was 8.2 ± 2.8.Overall, the pregnancy rate in this study was 10 (26.3%). As stated earlier, the 38 PCOS patients considered for this study were divided into 2 groups based on progesterone levels on the day of hCG injection in IVF cycles. The findings of this experiment are summarized in table 1.This study showed that clinical and chemical pregnancy outcomes in PCOS patients with progesterone levels above 1.2 ng/ml were higher than those whose levels were less than 1.2 ng/ml. However, no significant statistical differences were found.In two separate studies, Hoffman et al. , 6 showeIt appears that the results of various studies are in fact quite different. These observations or contradictory reports are related to many factors that affect IVF outcome. Induction ovulation is one factor which influences the quality of oocytes and implantation. Therefore, evaluation of serum progesterone levels before oocyte aspiration is complicated. Age, predisposing factors for IVF, and numbers of embryos also change IVF cycle results. The level of serum progesterone selected in various studies is not unanimous and therefore may affect the results.In conclusion, we recommend studies with more patients, taking into account the bias variable.