With increasing in application of U in nuclear energy and nuclear weapon, a large amount of U was dissipated into the environment including soil and water. Earthworm may be an eco-indicator for U bioaccumulation, transformation and transport across the ecosystem. There have been a variety of methods preformed to assess the bioaccumulation of uranium in small organisms such as earthworms, including uranium speciation, subcellular separation, and total U accumulation. All methods require an initial grinding preparation process that allows for the further fractionation of metals and metalloids in earthworms. The slime like mucus that coats the body of a worm presents a challenge in the disintegration and dissolution of the worm body. In order to analyze U subcellular forms, we developed a reliable and effective procedure to grind the worm body into a uniform fine suspension. We conducted a comparative study of disintegration of worms with 3 grinding techniques  that would assist U subcellular analyses and bioaccumulation. The essences of this new development was as follows:  Specifications table−1 in rocks and soils with an average of 3 mg kg−1Uranium (U), a natural trace element in earth crust, has been released into the environment through anthropogenic activities such as mining and processing, industrialization, nuclear power plants, and nuclear manufacturing as well as application of depleted uranium products. Uranium concentration is in a range of 0.3-11.7 mg kgDepleted uranium (DU) is the by-product of the U enrichment process. DU was used in military applications such as armor-piercing projectiles known penetrators and for armor-plating tanks based on its pyrophoric properties and high density. Several hundred tons of DU were released in military conflicts over the past forty years and DU was expected to remain in battlefields and army testing sites Uranium poses multiple health risks, especially chemical toxicity. DU is a low radioactive α-emitter material, therefore acute risk is not likely from external exposure. However, the potential hazard is a result from internal exposure, radiological and chemical effects Lumbricus terrestris was known as knight crawlers originated in Western Europe but became common species in North America through trade and immigration.Earthworms are an essential family of soil biomass and are viewed as a valuable marker of soil condition and quality. Earthworms are the environment's natural decomposers and they survive under a variety of habitat conditions that make them viable candidates for environment monitors Bioaccumulation is the accumulation of hazardous chemicals in any living organism such as plants, animal insects or other microorganisms. The longer the toxins remain present in the organisms, the stronger the effects of the toxins become regardless of the region having low hazardous chemical concentrations. Earthworm was used for bioindicators for many contaminants in soils such as Hg The methods we evaluated consisted of 1) Direct agate mortar grinding of fresh samples, 2) Liquid nitrogen freezing – agate mortar grinding, and 3) Sonication disintegration of the worms into the suspension solutions.1.Soil sampling and preparation.1.1.Soil samples were taken from Riley military base, KS at the depth 0–30 cm. The soil was sieved to remove particles greater than 2.00 mm.1.2.To produce simulated uranium contaminated soil for the control soil type, uranium schoepite (<250 µm) was added to produce U contaminated soil that contained 6,000 ppm uranium delivered through aging at 55°C for sixty days. For the dry spiking, schoepite (<250 µm) was mixed with 500 g dry soil in mixing pan and was mixed for 1 min. The soil sample was then passed through a sample splitter for a total of twelve times to ensure homogeneity. The remainder soil  was mixed as mentioned above and added and mixed for 8 × 1-min intervals. The spiked soils (4 kg) were placed in open plastic buckets for artificial aging in the environmental chamber at 55 degrees C. The samples were maintained at the water holding capacity (WHC) of 50% throughout the 60-day time period.2.Earthworm incubation in U spiked soils2.1.Diplocardia spp.) were purchased from a local community garden and were transported in generic pot soil and worm casting.About 0.5 kg of farm raised North American night crawlers (2.2.About 20-30 worms weighing at 2-3 grams were lightly washed with warm water.2.3.Worms were placed into the middle of the U soils to ensure the maximum exposure.2.4.Worms were exposed to the soils for 35 days. After 35 days of exposure worms were lightly cleaned and prepaired for purging (no worm casting was added to soil).3.Worm purging preparation3.1.After the initial soil exposure, three worms were extracted from each soil sample. Two layers of wet filter paper were placed into a petri dish with the worm samples.3.2.The worms were left for 48 hours to purge while keeping a consistently moist filter paper present.3.3.After purging worms were cleaned and were cut into smaller pieces using an exact knife and were placed aside for later use.4.Three methods were used to prepare the worms for U study: Agate mortar grinding technique, liquid nitrogen freezing then grinding, and direct sonication.5.Preparation Method 1: Agate mortar grinding technique with fresh earthworms5.1.Sections of three fresh purged worms (around 0.2 g) were extracted from each contaminated soil sample and cut into micro beads.5.2.The worms were then transferred to the well of the mortar and grinded to the finest form attainable.5.3.The worm was then placed in a 50 ml centrifuge tube and homogenized with the given solution and prepaired for further U subcellular study.6.Preparation Method 2: Liquid nitrogen freezing and grinding with agate mortars6.1.Sections of three fresh purged worms (around 0.2 g) were extracted from each contaminated soil sample and cut into micro beads.6.2.The worm samples were then frozen in liquid nitrogen for 24 hours. After freezing the samples were transferred to aluminum container and submerged in liquid nitrogen. As quick as possible, the sample was grinded with a metal mallet till the sample was in a fine form.6.3.The samples were transferred to a 50 ml centrifuge tube and homogenized with the given solution and prepared for further U subcellular study.7.Preparation Method 3: Direct sonication technique7.1.Sections of three fresh purged worms (around 0.2 g) were extracted from each contaminated soil sample and cut into micro beads.7.2.The worms were then transferred to a 50 ml centrifuge tube with 1-2 ml water and placed in the sonicator for three hours or until the solid sample turned to liquid.7.3.The samples were then homogenized with the given solution and prepared for further U subcellular study.8.Subcellular U forms in earthworms [14]8.1.Three subcellular U forms/ fractions were determined. Sections of three fresh worms (around 0.2 g) were prepared from three different preparation methods Steps 5-7.8.2.The prepared suspensions were placed in a 50 ml centrifuge tubes and its volume was made to 10 ml of the total suspension.8.3.The total volume (10 ml) of the suspension was divided into two equal portions (5 ml). The first portion with 5 ml of the mixture was used to determine the total U in the earthworm. A second 5 ml supsension was used for determinng the subcellular U forms.8.4.3 and ammonium hydroxide.One litter of a homogenized buffer solution was made using 0.0315 grams of tris HCL, 0.17419 grams of phenylmethane sulfanyl fluoride, 0.37224 grams of EDTA and 0.28838 grams of sodium dodecyl sulfate. The pH of the buffer solution was adjusted to 8.0 using HNO8.5.The buffer solution was added to the earthworm sample (5 ml suspension) until volume of the sample reached 15 ml. Samples were shaken for 10 minutes then centrifuged at 500 rpms for 5 minutes.8.6.2O2 on the hotplate until the solid was completely desolved. The digestion volume was brought up 10 ml then filtered with a 0.45 µm filter for inductively coupled plasma optical emission spectroscopy (ICP-OES) anaylsis.The pellet was considered as the cell membrane. The pellet was digested with 0.5 ml of nitric acid and 10 drops of 30% H8.7.2O2 until the solid residual was completely dissolved. The sample was brought up to 10 ml with water and filtered with a 0.45 µm filter for ICP analysis.The supernatant was brought up to 15 ml with water and centrifuged at 10,000 rpms for 30 minutes. The resultant supernatant solution was considered to be the cytosol fraction, including macromolecular organic matter and inorganic ions in the cytoplasm and vacuoles 9.Acid digestion of earthworms for the total uranium analysis9.1.A portion of fresh worm (5 ml) from Step 8.3. was placed into a 50 ml centrifuge tubes.9.2.3 and 2 ml of 30%H2O2 were added to the mixture and additional H2O2 was added as needed until all tissues were digested.Two ml of HNO9.3.After digestion the supernatant was filtered and set aside for ICPOES analysis.10.U in the filtered solution was determined with ICP mass spectroscopy (ICPMS) or ICPOES.Procedures:2 freezing following by agate mortar grinding generated the lowest total U and U subcellular forms. This implies that direct sonication method kept all original U without any potential loss during the preparation. Further, sonication method had the lowest coefficient of variation (CV%) between replications, while agate mortar grinding and liquid N2 freezing followed by grinding both had the much higher CV% (gher CV% . This inThe authors declared no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS.This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture.P = 0.006). Patients with SCI had more instances of subluxation or dislocation  and more cases of spinal epidural hematoma  than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004).Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3–C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates. Ankylosing spondylitis (AS) is a chronic inflammatory disease that mainly affects the axial skeleton. AS is characterized by progressive bone loss, erosion, and syndesmophyte formation, all of which lead to progressive spinal rigidity and altered spinal biomechanics . AS thusSpinal trauma includes spinal cord injury (SCI), spinal fracture, or both., 13, 14 Between January 1, 2006, and June 30, 2016, 6285 patients were treated for spinal fractures or SCI following a spinal injury at our institution. Of the 6285, only 110 patients with AS with spinal trauma were identified. The patients’ charts and images were reviewed by 3 experienced neurosurgeons. A rheumatologist confirmed the diagnosis of AS based on the criteria of the Assessment of Spondyloarthritis International Society , and 105Predefined and generally accepted parameters  at any point after injury were considered patients with SCI. We categorized SCI as either complete (AIS grade A) or incomplete (AIS grades B–D). Patients with SCI who demonstrated an improvement of at least 1 AIS grade (such as from D to E) during follow-up were considered neurologically improved.P < 0.05 was considered statistically significant. No adjustment for multiple testing (multiplicity) was made in this study. Data analyses were conducted using SPSS 25 .Data were presented as frequency and percentage for continuous variables and as mean and standard deviation for categorical variables. The patients included in the study were divided into 3 groups , and group 3: both SCI and spinal fracture). The characteristics of patients among the groups were compared using one-way analysis of variance for continuous variables or Fisher’s exact test for categorical variables. The improvement in AIS grade from the time of the first symptoms to the last follow-up in the patients with SCI was tested using the McNemar test. All tests were 2-tailed, and Of the 105 patients included in the study, 11 patients (10.48%) were in group 1, 45 patients 42.85%) in group 2 . Among these patients, all had spinal fracture; 6 of the patients were placed in the “doctor delay” group. Two of the 6 patients developed SCI at 5 days, and another 2 of the 6 developed SCI at 15 days after the trauma. The remaining 27 patients were placed in the “patient delay” group; 9 of the patients developed delayed SCI within 2 to 90 days after the trauma. The average time between trauma and a confirmed diagnosis for all the patients was 19.8 days (SD = 20.4 days), with a range of 2 to 90 days  with mild spinal fracture (AO spine fracture classification: A) received conservative treatment. Thirteen patients with mild spinal fractures (AO spine fracture classification: A) without SCI received conservative treatment. Of the 11 patients with SCI alone, 10 were cases of central cord syndrome, and they achieved recovery to AIS grade E; 1 case was a severe head injury with consciousness no recovery to clear. One, 4, 2, 3, and 1 injuries occurred at C3, C4, C5, C6, and C7, respectively. Anterior microdiscectomy with interbody fusion and fixation was performed in 2 cases; the 8 patients with mild SCI  and the 1 who initially presented with a deep coma received conservative treatment.SEH was observed in 14 patients (13.3%). Over the course of follow-up, 32 patients (30.5%) experienced complications, with infection being the most common (22.9%). Four patients (3.8%) died during the 2-year follow-up period; 3 of these deaths were due to pneumonia-related septic shock, and 1 was due to pulmonary embolism and cardiac failure with acute respiratory distress syndrome (Table P = 0.004). Among all 60 patients with SCI, 35 achieved an improvement in AIS grade. However, the AIS grades in 4 patients worsened due to the patients who died (n = 4) having been given an AIS grade A at the 2-year follow-up . Demographic and clinical characteristics were not significantly different, however, between the fracture and nonfracture groups or between the SCI and non-SCI groups. The results revealed that compared with the non-SCI group, more cases involving subluxation or dislocation , spinal fractures involving the C3–C7 region , spinal fracture in general (P < 0.001), and SEH occurred in the SCI group  and the SCI rate in cases also involving spinal fractures was 52.1% 49/94), which are similar to the rates in Europe and North America, which range from 19.7% to 67.2% 9/94, whi, 14, 18.Diagnoses of fractures in patients with AS are frequently delayed at a rate of 17.1% to 65.4%, 14 due P = 0.006; Table P = 0.367; Table P < 0.001). To clarify this discrepancy, we analyzed the relationship between bamboo spine and spinal fracture in the 60 patients with SCI. Four of the 11 patients who had SCI without spinal fracture presented with bamboo spine, and 43 of the 49 patients with both SCI and spinal fracture had bamboo spine. A comparison of these 2 groups revealed a significant difference . Subluxation or dislocation was also a risk factor for patients with AS developing SCI (P < 0.001). The severity of disruption to the spinal structure is, thus, predictive of SCI in patients with AS. In cases involving a complex fracture, SCI is not only caused by the damage from direct impact but also by further compression from bone fragments, hematoma, or disk material [Bamboo spine is a radiographic feature in AS that occurs as a result of vertebral body fusion by marginal syndesmophytes. The resulting radiographic appearance is of radiopaque spicules that completely bridge the adjoining vertebral bodies. In our study, 74.3% (78/105) of patients with AS exhibited this feature. We also observed that the patients with bamboo spine had a higher rate of spinal fracture than those without bamboo spine . SEH occurred in 13.3% of the patients with AS, which is a much higher rate than that of the general population (range: 0.5% to 7.5%) [All 14 patients with SEH developed SCI; SCI thus became a key predictive factor for SCI (to 7.5%) , 40. Comto 7.5%) , 40. SymP = 0.001) in patients with SCI. The 4 patients who died within 1 year were significantly older (with an average age of 69.2 years). This echoes previous findings of higher mortality in older patients with AS after spinal fracture [None of the patients who had complete SCI at admission exhibited improvement in AIS grade after 2 years. By contrast, 58.3% (35/60) of patients in the incomplete SCI group demonstrated improvement. Overall, patients with AS with incomplete SCI had better long-term neurological recovery. Complication rates were significantly higher (fracture , 13. Of This is a single-center study thus obviating patient selection bias. Besides, most subjects achieved long-term follow-up. Meanwhile, this study was limited for its retrospective design, as well as the non-feasibility of analysis on cervical, thoracic and lumbar cohorts separately due to insufficient case number. Thus, further well-designed prospective randomized studies are needed.SCI is a major complication of spinal trauma in patients with AS. After spinal trauma, patients with AS with bamboo spine have relatively high rates of spinal fracture. Cervical fracture involving the C3–C7 region, subluxation or dislocation, high severity, and SEH are predictive of SCI. In patients with AS, even low-energy trauma has the potential to cause spinal trauma, including SCI or fracture. Although the prevalence of AS differs across continents, the rate and predictors of SCI after spinal trauma in AS exhibit no obvious differences. Delayed diagnosis of fracture and SCI occur in approximately 30% and 10% of cases of spinal trauma, respectively. Therefore, attending physicians should be aware of their potential effects on patients with AS.


Ganglion is a commonly encountered soft tissue tumor. Most commonly patients seek treatment for cosmetic issues. There are a variety of treatment options available but very few are effective and cosmetically acceptable. Common treatment techniques have either high recurrence rates or have complications. Treatment by transfixation with linen suture under local anaesthesia on an outpatient basis is an upcoming treatment. The objective of the study is to find out the prevalence of successful outcome of transfixation techniques in treatment of dorsal wrist ganglion.This study is a descriptive cross-sectional study undertaken at a tertiary care center from November 2018 to May 2020. Ethical approval was taken from the same institution. Convenient sampling method was used. Patients presenting with dorsal wrist ganglion and consenting for the transfixation underwent the procedure. All the patients were operated under local anesthesia. Statistical analysis was done using Statistical Package for Social Sciences version 24.0. Point estimate was done at 95% Confidence Interval and frequency and percentage were calculated.Out of 30 cases, 29 (96.66%) have got successful outcomes with transfixation techniques. Among 30 patients, recurrences were seen in 2 (6.66%) cases. Patient satisfaction was high in 27 (90 %) cases. No complication was encountered.Transfixation technique had good results in terms of low recurrence rate, percentage resolution in size and high patient satisfaction. Sixty to seventy percent of ganglion cysts are found in dorsal aspect of wrist & communicate with joint via a pedicle.3 Surgical excision remains gold standard for treatment of symptomatic ganglion, but has complications.5 Transfixation with linen is a newer technique, which have shown promising result and can be carried out under local anesthesia as a day care procedure.6There are variety of modalities for treatment of ganglion cysts such as observation, aspiration, intralesional steroid injection, sclerotherapy, transfixation, arthroscopic resection, or surgical excision, but no one of these has been the standard treatment.The objective of the study is to find out the prevalence of successful outcome of transfixation techniques in treatment of dorsal wrist ganglion.The study was a descriptive cross-sectional study conducted in the Department of Orthopedics and Trauma Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu from November 2018 to May 2020. Study was started after getting clearance from the Institutional Review Committee. All patients presenting with ganglion over the dorsum of wrist were included in the study. Volar ganglion, infected ganglion cyst, ganglions less than 5 mm in size, patients with known immune compromised status , etc) and patients with local skin lesions  were excluded from the study. Convenient sampling was done and the sample size was calculated as,2 × p × q / e2n = Z2 × 0.95 × (1-0.95) / (0.08)2  = (1.96)  = 28.512Where,n= required sample sizeZ= 1.96 at 95% Confidence Interval (CI)7p= prevalence of successful outcome of transfixation techniques in treatment of dorsal wrist ganglion, 95% q= 1-pe= margin of error, 8%th day at the time of 1st dressing. Following the thread removal the patient was seen at 6 months. During the visit, the size of the swelling along with any other complication was assessed.Pro-forma was filled for each subject separately. Consent was taken from every patient. On the day of the procedure the patient was given 1gram of flucloxacillin orally, 1 hour before the procedure. Patients allergic to penicillin were given a single dose of erythromycin 500mg. Preoperatively, the skin surface over the ganglion was painted with betadine solution and the region infiltrated with a 2% xylocaine injection. An aspiration was performed to confirm that the swelling under consideration is a ganglion. A clear jelly-like fluid was considered to be confirmatory. Following this, No. 2'0 linen thread was passed through the swelling in two planes perpendicular to each other. Firm pressure and gentle message at the center of the ganglion continued until the swelling completely disappeared. The massage resulted in expulsion of the mucinous contents from the ganglion on the skin surface. The thread was removed on the 4Calculated score= score of parameter (1+2+3)/3.8Overall results were then calculated on the basis of the percentage of resolution in size and the level of patient satisfaction. Reiterative surgery was classified as poor. Accordingly they were classified into 4 categories: Excellent, Good, Fair and Poor .8Data was entered in Microsoft Excel sheet. IBM Statistical Package for the Social Sciences (SPSS) version 24 was used to analyze the data. Descriptive statistics were presented with frequencies and percentages for categorical variables. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage.Out of 30 cases, 29 (96.66%) got successful outcomes with transfixation techniques. Mean age of the patients was 28±10.6 years .Twenty-four (80%) were females and 6 (20%) were males. Dominant hands were involved in 20 (66.66%) whereas ganglion in nondominant hands were found in 10 (33.33%). Left side was involved in 14 (46.66%) and the right side in 16 (53.33%) cases .The time of presentation was less than 1 year in 9 (30%) cases, 1-2 years in 17 (56.66%) cases and 2-4 years in 4 (13.33%) cases.2 and minimum size being 1.5cm2 with mean being 5.5+/-2.9cm2.Range of length of ganglion varied from 1 to 4 cm with mean being 2.3±0.6. Range of breadth of ganglion varied from 1.2 to 3.6cm with mean being 2.3±0.5. Maximum size was 14.04cmRecurrence was present in 2 (6.66%) cases. Recurrences were in dominant hands.Patient satisfaction score at 6 months of follow up was high in 27 (90%) and moderate in 2 (6.66%), poor in 1(3.3%) cases. Overall results were excellent in 27 (90%) and good in 2 (6.66%), poor in 1 (3.33%) cases .10 Different modalities of treatment have been used in the treatment of ganglion cyst ranging from historically hitting with book/bible,aspiration alone, aspirations and injection of corticosteroid with or without hyaluronidase,injection of sclerosing agent, transfixation with suture, radical surgical excision, arthroscopic excision or simply reassurance to the patient.13 Despite several options in treating ganglion cyst, recurrence is the main problem encountered. Success rate of various modalities varies considerably.12Ganglion cyst in dorsum of hand is the commonly encountered benign soft tissue lump constituting approximately 50 to 70% of swelling of hand and wrist.17 Radical surgery, where ganglia were excised with underlying portion of joint capsule, has low recurrence but high complication rates like persistent pain due of damage to posterior interosseous nerve, scapholunate dislocation, joint stiffness and decreased grip strength.18The recurrence rate of ganglions after surgery is quite high.19Even arthroscopic resection of dorsal wrist ganglion, that has gained some momentum in recent years, has high recurrence rate and complications.7 We wanted to study the results of treatment of ganglion cyst by relatively new OPD procedure-transfixation with linen.Safer, reliable and minimally invasive out-patient department (OPD) procedure for the management of dorsal wrist ganglion has always been searched for.7Transfixation of the ganglion with linen is based on the principle that after the procedure, there is acute inflammation within 24 hours. By the end of 3 days, there is laying down of granulation tissue mainly by activation of fibroblasts present in the wall of ganglion. This leads to fibrosis which is complete by 8-10 days.21 appears to be related to the more involvement of that age group in both indoor and outdoor activities.The mean age was 28+/-10.6 with age range 10-60 years. The relatively common age group in our study as in other studies22 It can be due to early visit to doctor for cosmetic issues among females.In our study, females were affected more than males. Out of the 29 patients enrolled in the study, 25 were females and remaining 5 were males comprising of 83.3% of females. Females are most commonly enrolled in our study similar to other studies.21 can be explained by the fact that dominant hand is used in various indoor and outdoor activities.Dominant hand was involved in 19 (65.5%) cases whereas non-dominant hand was involved in 10 (34.5%) cases in our study. Involvement of dominant hand in our study like in other studiesIn our study, the patients presented with concern of cosmesis in 9 (30%) cases, concern of cosmesis and fear of malignancy in 14 (13.33%) and concern of cosmesis and pain in 17 (56.67%) cases.20 reported, 20 cases (55.56%) complained of pain, 6 cases (16.63%) complained of pain with cosmesis and 6 cases (16.67%) complained of cosmesis and 4 cases (11.11%) presented with fear of malignancy among 36 cases. Rishi Singhal, et al.7 reported pain in 46.2%, followed by cosmesis in 34.6%. Ajaz Ahmad Shah, et al.22 reported swelling was the main complaint in 86 cases (100%) followed by pain and discomfort in 52 (60.46%) cases, cosmetic in 49 (56.98%) casesand apprehension of tumor in 34 (39.53%) cases. Rathod, et al.7 reported cosmesis as the main complaint in 20 (50%) cases followed by pain and cosmesis in 15 (37.5%) cases and pain only in 5 cases.In a study conducted by Sharma Man Mohan, et al.In our study, time of presentation varied from 1.5 months to 4 years since onset. Out of 30 cases, 17 (56.66%) presented within the range of 1 to 2 yrs. Delay in time of presentation was seen in some of our cases as they were initially less concerned about the disease.7 reported 1 to 2.5cm size at the time of presentation with mean size of 2.04+/-0.45cm. Similarly Sharma Man Mohan, et al.20 also reported size ranging form 0.7cm to 3cm with mean being 1.86 cm.The size at the time of presentation varied from 1 cm to 4 cm, mean being 2.3+/-0.6cm, in our study. Rishi Singhal, et al.22 who used silk 2/0, we used linen which is a natural twisted multifilament and highly fibrogenic. For this purpose this makes it one of the most suitable suture materials available. Silk on removal leaves pigmentation in the dermis which is undesirable cosmetically to the fair skinned. No lingering pigmentation was seen with the use of linen.The technique used by us has several advantages. There was no need of hospitalization and the problems of scar, keloid formation and hypertrophy are completely avoided. In contrast to Gang and Makhlouf et al.22 Similar study by Rathod, et al.7 in which suture was removed after 4wks reported infection in one case at 10th day of dressing. Bhavinder Arora, et al.10 in which out of 150 patients, 6 cases reported infection. In our study, suture was removed in 4th day, so the need for repeated dressings was obviated. It also prevented infection. None of the patients presented with infection and pigmentation.The thread was removed at 3 weeks by Gang and Makhlouf and reported 10 % infection rate.20 reported recurrence in 2 (2.56%) cases with transfixation with linen. Rathod, et al.7 reported a recurrence in one (2.56%) case using transfixation technique with silk suture.In our study, 2 (6.66%) cases had recurrence. Recurrences were seen in the dominant hands. Sharma Man Mohan, et al.8 high or moderate satisfaction were obtained in 24 patients (92.3%). An overall success rate (Excellent and Good) of 76.9% was achieved with transfixation of ganglion with linen threads.In our study, the patient satisfaction score at follow-up was high in 27 (90%) and moderate in 2 cases (6.66%). Overall results were excellent in 27 (90%) cases and good in 2 (6.66%) cases in the transfixation group. In a study conducted by Rishi Singhal, et al.There were no complications encountered such as scar marks, functional limitation, infection etc.The limitations of our study were that the principal investigator was unblinded which may have led to observer bias. Small sample size and short duration of study and short time for follow-up were other limitations.Transfixation with linen for the treatment of ganglion cyst had low recurrence rate and high patient satisfaction. Transfixation technique with linen is a minimally invasive procedure, which was found to be effective and cosmetically acceptable in treatment of dorsal wrist ganglion. Our findings were similar to other studies on transfixation with linen for ganglion. We recommend the use of this technique as an outpatient procedure in our setup too.


Diabetes case conferencing is where an endocrinologist visits a general practitioner (GP) to advise on the care of patients with diabetes. Past case conferencing studies have reported improved diabetes management and clinical outcomes in primary care. This study investigated the effectiveness of a diabetes case conferencing program in South Western Sydney, Australia.Complex diabetes cases were referred by general practitioners to a visiting endocrinologist for review after obtaining patient consent. The patient was not usually present. After the case discussion, a diabetes management plan was developed jointly by the general practice/specialist team. Clinical data were compared at baseline and each year up to three years (2017–2020) after the consultation using paired t-test. The primary outcome was HbA1c.2 (p < 0.001).Clinical data were collected for 645/775 patients (mean age 64 ± 15(SD) years; 351 (54.4%) males from 40/43 general practices; 96.4% had type 2 diabetes; 6.5% were insulin treated, 54.3% non-insulin treated, 31.5% both insulin and non-insulin treated and 3.4% diet only. There were reductions in HbA1c by 1.0 ± 1.7% (11 ± 19 mmol/mol) (p < 0.001), systolic blood pressure 8.2 ± 18.1 mmHg (p < 0.001), diastolic blood pressure 2.7 ± 11.6 mmHg (p < 0.001), total cholesterol 0.2 ± 1.7 mmol/l (p = 0.007), low-density lipoprotein 0.2 ± 1.0 mmol/l (p < 0.001), weight 3.3 ± 10.1 kg (p < 0.001) and body mass index (BMI) 1.3 ± 3.5 kg/mGlycaemia, weight and cardiovascular risk factors improved following case conferencing consultations in a primary care setting. The diabetes epidemic is a growing health challenge in both Australia and globally. It is a chronic and complex disease and was among the top 10 causes of death at a global level in 2019 [Mechanisms to improve integration between primary and secondary care are particularly important when managing complex cases in countries where the diabetes care is fragmented . SpecialCase conferencing/multidisciplinary case conference is where patient histories/cases are reviewed , their multidisciplinary care needs are identified, and the best pathway forward is planned . Several789101112In Australia, approximately 1.2 million had diabetes in 2017–18 with the prevalence higher among those aged 65–74 years 15.4%) and in the lowest socioeconomic areas (7.0%) . Diabete.4% and i1011Diabetes is a significant health burden in South Western Sydney, a multi-ethnic area with 966,450 people in 2016), 10.8% of whom have diabetes, and with increasing prevalence estimates over time [, 10.8% oParticipating sites were general practices across seven Local Government Areas (LGA) in South Western Sydney who referred patients for a case conferencing consultation. All general practices (n = 422) were invited to participate through the usual communication channels of the Primary Health Network. Baseline clinical data were collected from the participating general practices at the time of consultation and the follow-up clinical data were collected after at least 6 months of the initial consultation. Between 2017–2019, case conferencing endocrinologists were assigned a LGA to provide consultations. There were up to three endocrinologists at any time sharing a 0.7 full time equivalent workload. Endocrinologists visited the general practices for a face to face case conferencing session without an extra cost to the patient. A third healthcare professional from the hospital (diabetes educator) or general practice also participated in the case conferencing, who could be a dietitian, diabetes educator, podiatrist or a practice nurse. Any health professional member of the general practice involved with the patient(s) could attend. The patient was rarely present as part of the program to facilitate scheduling, wider discussion and to allow greater numbers of patients to be discussed in the limited time available. Timing assumed 15 minute slots. A patient could be present at the insistence of the GP. GPs had access to billing for the Medicare Benefits Schedule chronic disease items for organising and coordinating a case conference. They are paid depending on the time spent on case conferencing (Supplement table 1). The diabetes case conferencing program remains ongoing in South Western Sydney. Time of the consultation was agreed mutually between the GP and endocrinologist, which could be at lunchtime (food was not provided) or a regular appointment time when there were no patients booked in for a consult. Endocrinologists work on certain days of the week; therefore, the appointments could only be booked on those days.General Practitioners were asked to prioritise and refer complex cases with longstanding management challenges where the HbA1c is ≥ 9% (75mmol/mol) and those with significant and frequent hypoglycaemia, with diabetes complications present , blood pressure over 160/100 mmHg, triglycerides 10+mmol/l and other patients that GPs would like to discuss. Each case conferencing consultation lasted approximately 15 minutes for each patient. Patient consent  prior to the consultation was required. During a case conferencing consultation, patient cases were reviewed  and their multidisciplinary care needs were identified.Clinical variables included HbA1c, systolic blood pressure (SBP) and diastolic blood pressure (DBP), derived BMI, weight, blood lipids, serum creatinine, eGFR , urine albumin creatinine ratio, and their current medication from before, after and annually after the consultation where available. The Royal Australian College of General Practitioners (RACGP) treatment targets on the management of type 2 diabetes were used to describe the proportion of patients achieving clinical target/range before and after the consultation .2 = group 1, 25–29.9 kg/m2 = group 2 and ≥30 kg/m2 = group 3), diabetes duration (above and below median- 8 years), and age groups (above and below median age (64 years).Data were analysed using the Statistical Package for Social Sciences (SPSS) 27 software. Descriptive statistics included percentages for categorical variables, mean± standard deviation, or median (range) for continuous variables. Paired t-tests were used to compare pre- and post-consultation clinical data and repeated measures to explore changes in mean HbA1c, SBP, DBP, total cholesterol and weight over three years from year 2017–2020. To assess differential impact for those with more/less hyperglycaemia, the cohort was divided into quartiles based upon average HbA1c – (1) <7.5%, (2) 7.5–8.6%, (3) 8.7– 10.0%, (4) >10.1% with a paired t-test performed to compare the baseline and follow-up HbA1c within each group. Ages were grouped into quartile with approximately equal number of patients in each group: <55 years (group 1), 55–64 years (group 2), 65–74 years (group 3) and >75 years (group 4) and HbA1c was also compared within these groups. The Wilcoxon signed-rank test was used to compare the non-normally distributed pre- and post-case conferencing UACR and serum creatinine. McNemar test was used to see if there was difference in the paired group, to compare groups achieving clinical targets and if the groups were statistically significant before and after the intervention. All tests are two tailed with p <0.05 considered statistically significant. To investigate whether the intervention was more effective in reducing the HbA1c in any patient subgroups, a binary logistic regression using Bayesian method was performed and missing data values were imputed in multiple imputation by using fully conditional specification (FCS MI) method in SPSS. Two patient groups above and below the median difference in HbA1c were created. Patient groups included were gender (men and women), BMI groups according to RACGP classification criteria  were men, mean age was 64 ± 15 years with median (range) diabetes duration eight (1–43) years, 96.4% had type 2 diabetes and 3.6% type 1 diabetes. Overall, 14.5% patients were smokers and 22.8% ex-smokers. Alcohol was consumed by 24.9% patients and 2.6% were ex-drinkers. Nineteen patients had more than one case conferencing consultation. The ethnicity of patients was not documented in most of the GP records and was therefore not included in the analysis. Forty-two patients were treated with insulin only (6.5%), 350 patients were treated with tablets/Glucagon-like peptide-1 receptor agonists (GLP1 RA) (54.3%), 203 (31.5%) patients received combined insulin/non-insulin therapy and 22 patients (3.5%) with diet alone. Diabetes complications were common with 26.7% patients having an eye complication, 22.2% kidney disease , 73.8% had cardiovascular disease (68.2% had hypertension), 9% had cerebrovascular disease, 3.7% had a lower limb amputation, 23.9% had depression and 49.9% patients had more than one complication. Mean HbA1c for patients (n = 56) lost to follow-up was 9.2% and 62.5% had cardiovascular disease. There were no baseline data for 25 patients.The time between the baseline and follow up data collection was a median of 30 months (9–33 months). There was a decrease in the prescription of non-insulin medication and insulin only, and an increase in a combination of insulin and non-insulin prescription. Of the 90 patients who had CKD, 34.5% patients remained treated with metformin treatment after the consultation, 23.3% patients were no longer receiving metformin, and 8.9% patients were prescribed metformin post consultation and 33.3% patients were not on metformin treatment.Among those with repeat data from 2017 (n=196), the HbA1c , SBP, DBThe binary logistic regression showed no difference in effect among those above and below the median HbA1c by age, diabetes duration, gender and BMI groups according to RACGP classification criteria. However, HbA1c reduction was more likely to occur among those aged below 64 years (odds ratio (OR) = 1.91, 95% CI (1.25–2.93).This is the first pre- post evaluation of patient-free diabetes case conferencing in a primary care setting. Despite only lasting approximately 15 minutes, this form of diabetes case conferencing was associated with significant reductions in glycaemia [mean HbA1c drop of 1% (11 mmol/mol), systolic blood pressure (mean drop of 8 mmHg), diastolic blood pressure (mean drop of 3 mmHg), lipids and weight. Glycaemic outcomes improved significantly in the first year in patients who visited their GPs annually for follow-up, and was then maintained in the following years. The proportion of patients achieving targets increased for HbA1c, blood pressure, total cholesterol, triglycerides and LDL after the consultation. There was also a significant improvement in HbA1c in all age groups and in both men and women. Patients who were hard to manage were referred by their GPs to an endocrinologist for case discussion. This study is built upon the vanguard diabetes case conferencing patient-free consultations in the South Western Sydney .Besides the case conferencing sessions and associated travel, cancelled sessions and availability for sessions, the 0.7FTE endocrinologists were also involved in approaching new general practices to participate in the program and district wide primary care education activities. The degree of endocrinologist downtime remained dependent on the success of the local Primary Health Network general practice communication activities and subsequent number of general practices engaging in the case conferencing program. Initially before COVID-19, all case conferences were face to face. During the COVID-19 pandemic, case conferencing telehealth was used.Recent evidence on diabetes care highlights that case conferencing programs can help close the gaps in service provision such as barriers between different settings, improve patient experience by accommodating more complex cases in primary care and reduces duplication of care 12. In tw10Several diabetes integrated care studies internationally have reported improvements in metabolic outcomes and cardiovascular risk factors, reduction in hospitalisation, improved quality of care, increased service cost-effectiveness, improved clinical outcomes among indigenous population and rural communities and an opportunity for shared learning 913. Inte9In Australia, similar integrated diabetes care approaches  also reported a significant reduction in HbA1c from 0.4-1% (4.7 mmol/mol -10.2 mmol/mol), significant associated reductions in blood pressure and total cholesterol, improved patient and GP satisfaction and upskilling the general practitioners in their practice setting 810121820. R121878According to the American Diabetes Association in their Standards of Medical Care, when possible, emphasis should also be placed on reducing cardiovascular risk . PatientStrengths of this study include that it was a district-wide program across an area with six public and three private hospitals including the largest number of patients participating. The study had a low loss to follow up rate of only 16.8% (n=130), 93% of the general practices involved in case conferencing participated and it is the first patient-free case conferencing. The study captured comprehensive data over a period of three years. This case conferencing model was shown to be suitable in both urban and rural settings where a number of participating practices support large multi-ethnic populations with varying socioeconomic status. Weaknesses include being a single arm intervention study without a control group. The lost to follow-up patients were those who changed their GPs in the middle of the treatment, receiving care from multiple practices and may have had different outcomes to those remaining with their GP. We were unable to capture the ethnicity for most patients; however the population ethnicity is diverse in all seven LGAs . Future In summary, we have shown that this case conferencing model, where the patient is not present allows cases to be discussed quickly  and is associated with substantial improvements in management of patients with complex type 2 diabetes. It can also help clinicians in identifying critical areas and reduce clinical inertia. The results from this study show that this model can make significant contribution to the diabetes management in the primary care setting compared to the existing fragmented approach with delayed or absent support. A randomised controlled trial, including a cost effectiveness/cost utility study would be ideal to test the robustness of these results.The additional files for this article can be found as follows:10.5334/ijic.6545.s1Supplementary Figure 1.It shows the change in mean SBP, DBP, total cholesterol and weight for each year from 2017–2020.10.5334/ijic.6545.s2Supplement Table 1.It shows the Medicare Benefits Schedule chronic disease items for organising and coordinating a case conference.


Mean arrhythmia-free survival after 12 months was 85.1 ± 4.7%. High-density mapping in combination with coherent mapping may facilitate the understanding of the tachycardia mechanism, providing targets for effective ablation.The present study describes our experience with a new mapping approach for ventricular arrhythmia (VA) ablation in patients with structural heart disease (SHD). Consecutive patients undergoing catheter ablation for recurrent VA were analyzed. High-density mapping was conducted in all patients. In patients with inducible VA, local activation time (LAT) mapping and a novel vector-based mapping algorithm were implemented to analyze arrhythmia propagation. In case of focal tachycardia, the location of earliest activation was targeted. In VAs with re-entrant mechanisms, zones of slow conduction based on coherent mapping were ablated. Substrate modification was performed when pathologic electrograms were identified. Seventy-four patients were included. Sixty-five patients (87.8%) were male. Ischemic cardiomyopathy was the underlying disease in 35 patients (47.3%) and nonischemic cardiomyopathy was the underlying disease in 39 patients (52.7%). Mean left ventricular ejection fraction was 33.8 ± 9.9%. Non-inducibility of any VA was achieved in 70 patients (94.6%). Termination of VA was achieved in 93.5% of patients with stable VA. In 4 patients (5.4%), partial success was achieved. VA ( Ventricular arrhythmia (VA) is a leading cause of mortality and morbidity in patients with structural heart disease (SHD) ,2. ImplaData from consecutive patients undergoing radiofrequency-based catheter ablation due to recurrent VT between January 2020 and December 2021 at our institution were analyzed. All patients gave written informed consent before participating. The study followed the principals outlined in the Declaration of Helsinki and was approved by the local ethics committee (2019-563). The study was conducted as a prospective observational study as part of the institutional catheter ablation registry. Baseline, procedural and follow-up data were collected and statistically analyzed.Left ventricular thrombi were ruled out by transthoracic echocardiography in all patients prior to ablation. Atrial thrombus formation was ruled out by preprocedural transesophageal echocardiography in patients with high risk for left atrial or left atrial appendage thrombi. Interrogation of cardiac devices was conducted prior to ablation and tachycardia therapy was deactivated. Patients with medication of vitamin K antagonists received uninterrupted anticoagulation with a target INR of 2.0 to 3.0. In patients with preexisting treatment of direct oral anticoagulants (DOAC), uptake was paused one half-life before the procedure and continued within 4 h after ablation. All procedures were conducted in general anesthesia. During ablation continuous monitoring of heart rate, oxygen pressure, invasive measurement of blood pressure and body temperature was performed. Heparin administration for systemic anticoagulation was started after left heart access targeting an ACT > 300 s.Transseptal puncture was performed using a BRK-1 needle and a steerable sheath with electrodes allowing its visualization inside the 3D mapping system . Two diagnostic catheters were introduced and positioned into the coronary sinus  and the right ventricle . Right and left ventricular ultrahigh-density mapping was conducted in all patients using a 3D electroanatomic mapping system  aiming >1000 mapping points. Bipolar voltage mapping of the left ventricle was conducted during sinus rhythm, intrinsic atrial rhythm or ventricular pacing by ante- and retrograde access with a multielectrode catheter . Epicardial access was assessed by dry epicardial puncture with conventional needles if the clinical VA was morphologically suspected to be of epicardial origin, or in case of ineffective endocardial ablation attempts. A steerable sheath  was inserted into the epicardial space. Low-voltage areas were defined as bipolar voltage of <1.5 mV in endocardial mapping and 5–8 mV in epicardial mapping. Programmed ventricular stimulation was performed before ablation in all patients for tachycardia induction. Catheter ablation targeted induced VA as well as substrate modification of abnormal intracardiac EGMs based on high-density mapping. Local abnormal ventricular activity (LAVA) was defined according to previously published criteria . If VA wCoherent mapping is a novel feature of the CARTO 3 system providing an additional method to visualize electrical arrhythmia propagation by color coding and direction vectors . The cohAll patients were transferred to a wake-up area after the procedure. Extubating was performed postprocedural while the patient was still in the electrophysiology laboratory before being transferred to a wake-up area and the ward. Patients who underwent epicardial puncture for ablation were monitored for at least 24 h post-procedure in the intensive care unit. Epicardial drainage by a pigtail catheter was continued after epicardial ablation until no relevant amount of pericardial effusion could be aspirated and serial echocardiographic imaging showed no evidence of pericardial effusion. The regularly scheduled in-hospital stay after ablation was at least two days. Clinical FU was conducted at our outpatient clinic after 3, 6 and 12 months, including assessment of the clinical history and 12-lead ECG. In patients without intracardiac devices, 72 h Holter ECGs were performed. Subsequently, clinical visits were conducted every 12 months at our outpatient clinic. Device interrogation was conducted in patients with implantable cardiac devices at presentation. If available, device interrogation by remote monitoring was conducted every 4 weeks or immediately in case of sustained arrhythmia episodes. Arrhythmia recurrence was defined as any documented sustained VA with or without ICD therapy. Inadequate ICD therapy due to atrial arrhythmia or sensing issues was not counted as VT recurrence after ablation.n, %). Arrhythmia-free survival was estimated with the use of Kaplan–Meier curves. All p-values were two-sided and a p-value < 0.05 was considered statistically significant. All calculations were performed with statistical analysis software .Continuous data were summarized as means +/− standard deviations and categorical data as absolute and relative frequencies  and NICM was the underlying disease in 39 patients (52.7%). Mean left ventricular ejection fraction was 33.8 ± 9.9%. Average glomerular filtration rate was 61 ± 15.4 mL/min. Oral anticoagulation was present in 46 patients (62.2%), with 50% of the patients receiving vitamin K antagonists and 50% receiving DOAC. Antiplatelet therapy was present in 26 patients (35.1%). Continuous antiarrhythmic drug therapy before catheter ablation was administered in 48 patients (64.9%). Of these patients, 91.7% were on continuous medication with amiodarone and 8.3% were on continuous medication with sotalol.A total number of 74 patients were analyzed . Sixty-f2. Epicardial puncture and ablation was performed in 10 patients (13.5%). Mean ablation time was 34 ± 16.21 min. Mean mapping time during sinus rhythm was 7 ± 5.18 min for the right ventricle and 26 ± 9.88 min for the left ventricle. Mean number of points taken during left ventricular voltage mapping was 2044.76 ± 1269.81 points. Mean time of tachycardia mapping was 9 ± 1.78 min. Average number of points taken for local activation times (LAT) during tachycardia was 1286.62 ± 217.29 points. Mean volume was 132.89 ± 43.11 mL for the right ventricular and 281.62 ± 101.75 mL for the left ventricle. The average extent of low-voltage areas was 19.6 ± 17.18% (Mean procedure duration was 167 ± 27.68 min with a mean fluoroscopy time of 11 ± 16.5 min with a mean area dosage product of 1319.04 ± 121.67 cGy*cm± 17.18% .VA was inducible in 65 patients (87.8%). In 31 patients (41.9%), the induced VA was stable, and mapping could be performed. In 29 patients (93.5%), stable VA during the procedure termination by ablation, based on findings during coherent mapping, was achieved. Mean FU duration was 221.64 ± 25.78 days. Recurrence of sustained VT after ablation was observed in 15 patients (20.3%). Mean time to recurrence was 247 ± 183.51 days. ICD therapy after ablation occurred in 12 patients (16.7%) after ablation with anti-tachycardia pacing (ATP) in 11 patients (15.3%) and ICD shock delivery in 7 patients (9.7%). During the follow-up period 9 patients died (12.2%), with 7 patients (77.8%) experiencing a non-cardiovascular event. Of the remaining two patients (22.2%), one died due to cardiogenic shock after recurrent VA and the other one died due to low-output syndrome in the context of chronic left ventricular dysfunction .p = 0.737)Survival analysis using the Kaplan–Meier method showed an arrhythmia-free survival of 85.1 ± 4.7% after 12 months for all patients A. In patp < 0.001), ATP (p < 0.001) and ICD shock burden (p = 0.001) were significantly reduced in all patients after VA ablation (Mean number of VA six months before ablation was 10.23 ± 1.69 episodes. Mean number of ATP and ICD shocks before ablation was 11.75 ± 2.01 and 4.22 ± 1.23, respectively. After ablation mean number of VA observed during follow up was 0.53 ± 0.16 episodes, mean number of ATP was 0.55 ± 0.17 and mean number of ICD shocks was 0.07 ± 0.05. VA (ablation .The present study elucidates the effectivity of VA ablation in patients with SHD based on high-density mapping, implementing a novel velocity-vector-based mapping algorithm. To the best of our knowledge, this is the first study systematically analyzing a coherent-based mapping strategy for ablation of VA.Ablation of VA based on high-density, velocity-vector-based mapping was performed with short procedural duration and low complication rates.Intraprocedural termination of induced VA was achieved in a high number of patients using the novel mapping algorithm.Ablation of VA based on the present approach was associated with high acute and mid-term success rates in patients with ICM, as well as in patients with NICM.A significant reduction in VA burden and consecutively of ICD therapy burden was observed in all patients after VA ablation.The main findings of the study are as follows:Today, catheter ablation of VA is an established therapy in patients with recurrent VA refractory to medical treatment or in patients who poorly tolerate medical therapy . Since tCoherent mapping is a novel feature of the CARTO 3 system providing an additional method to visualize electrical arrhythmia propagation based on velocity vector identification, enabling identification of critical arrhythmia components. Recently, this novel mapping module has been evaluated in ablation of complex atrial tachycardia and was shown to be effective in identification of tachycardia mechanisms ,21. To tIn the present study, we observed high acute and mid-term procedural success rates. Acute procedural success defined as non-inducibility of any VA at the end of the procedure was achieved in over 90% of the patients. Survival estimation based on clinical follow up showed an arrhythmia-free survival after 12 months of 85% in the overall patient population, with high effectiveness even in patients with NICM. According to the randomized DANISH trial, primary prevention implantation of ICD did not show mortality benefits in patients with NICM . HoweverThe study had an observational design and therefore has the typical limitations in terms of data acquisition. Furthermore, the study population was relatively small. Cardiac magnetic resonance imaging was not performed prior to ablation and might have added further information on VA foci. A potential limitation might be that the present study represents feasibility and outcome of VA ablation in a highly experienced electrophysiological center with trained staff, so that our findings may differ in less-experienced centers. The most important limitation of the study is the lack of a control group, so that a definite conclusion on the possible facilitation of VA ablation by combination of coherent mapping and high-density LAT cannot be made. Further studies in the field are warranted.Catheter ablation of VA in patients with structural heart disease is safe and associated with high success rates in terms of reducing VA burden and, consecutively, the delivery of ICD therapy. High-density mapping in combination with coherent mapping possibly facilitates the understanding of tachycardia mechanisms, providing targets for effective ablation.


The infant mortality rate (IMR) is considered a basic measure of public health for countries around the world. The specific aim of our study was to provide an updated description of infant mortality rate among different regions in rural China, and assess the trends and causes of the IMR geographical disparities.Data were collected from China’s Under-5 Child Mortality Surveillance System(U5CMSS). The annual number of deaths and causes of death were adjusted using a 3-year moving average underreporting rate based on annual national data quality control results. The average annual decline rate (AADR) and the relative risk (RR) of the IMR and cause-specific infant mortality were calculated by Poisson regression and the Cochran–Mantel–Haenszel method. Data analysis was completed by SAS software.There was an apparent decrease in infant mortality in rural China from 2010 to 2018, at the AADR of 11.0% (95%CI 9.6–12.4), 11.2% (95%CI 10.3–12.1) and 6.6% (95%CI 6.0–7.3) in the eastern, central and western rural areas, respectively. The IMR was highest in the western rural area, followed by the central and eastern rural areas. Compared with the eastern rural area, the RR of infant mortality in the central rural area remained at 1.4–1.6 and increased from 2.4 (95%CI 2.3–2.6) in 2010–2012 to 3.1 (95% CI 2.9–3.4) in 2016–2018 in the western rural area. Pneumonia, preterm birth /LBW and birth asphyxia were the leading causes of infant deaths in the western rural area. Mortality rates of these three causes fell significantly in 2010–2018 but contributed to a higher proportion of deaths in the western rural area than in the central and western rural ares.Our study indicated that the infant mortality rate dropped significantly from 2010 to 2018, however, geographical disparities of IMR in rural China are still persist. Therefore, there is an urgent need for public health programmes and policy interventions for infants in western rural China. The infant mortality rate (IMR) is considered a basic measure of public health for countries around the world, reflecting the apparent association between the causes of infant mortality and other factors that are likely to influence the health status of the whole population such as their economic development, general living conditions, social well-being, rates of illness and the quality of the environment , 2. EconChina represents a unique example of success in achieving the Millennium Development Goal 4(MDG4) target of reducing the under-5 mortality rate by two-thirds between 1990 and 2015 . China hEffective programs to reduce the infant mortality rate in rural areas require accurate epidemiological characteristics of infant deaths. One article investigated the trends and causes of the IMR geographical disparities from 1996 to 2008 in rural China . HoweverThe data were obtained from the China’s Under-5 Child Mortality Surveillance System (U5CMSS), a population-based monitoring system used to collect important statistics on child mortality levels and causes of death. There are approximately 47.1 million individuals across 334 representative sites in the 31 provinces of mainland China . In thisDoctors from the township hospital or community health service centre performed household surveys for each death in their respective areas, described the symptoms before the death in detail on the child death registration card, and assessed the causes of death. The cause of death was determined from death certificates in the case of children who died in the hospital, hospital-reported medical diagnoses in the case of children who received health care before their death, or verbal autopsies when medical records were not available. All causes of deaths were confirmed by pediatricians at maternal and child health institutes at the county, municipal and provincial levels. Furthermore, the neonatal death review program and the under-5 child death review program were implemented at most surveillance sites before nationwide implementation in 2009. These programs mainly focused on the assessment of causes of death.2 trend test. An infant’s diagnostic level composition ratio was calculated based on the reported child death report card, excluding children who died from accidental injuries [In this study, U5CMSS data are available for each year in the period from 2010 to 2018. Infant mortality was defined as the number of deaths per 1000 live births, and the rate of cause-specific infant mortality was calculated as the number of cause-related deaths per 100,000 live births. The infant mortality and cause-specific infant mortality were adjusted by the 3-year moving average under-reporting rate based on annual national data quality control results . The aveinjuries .All statistical analyses in this study were performed using SAS software.p < 0.001) , 11.2% (95%CI 10.3–12.1) and 6.6% (95%CI 6.0–7.3), in the eastern, central and western rural areas, respectively, , neonatal mortality rate (NMR) and post-neonatal mortality rate (PMR) in rural China. The rates were the highest in the western rural area, followed by the central and eastern rural areas. Compared with the eastern rural area, the RR of IMR remained at 1.4–1.6 in the central rural area during 2010–2018, and increased from 2.4 (95%CI 2.3–2.6) in 2010–2012 to 3.1 (95%CI 2.9–3.4) in 2016–2018 in the western rural area. Using the eastern rural area as the reference, the RR of NMR decreased from 1.6 (95%CI 1.5–1.8) in 2010–2012 to 1.4 (95%CI 1.2–1.5) in 2016–2018 in the central rural area, and remained at 2.4–2.8 in the western rural area. The RR of PMR in central and eastern rural areas increased from 1.3 (95%CI 1.1–1.4) and 2.4 (95%CI 2.2–2.7) in 2010–2012 to 1.8 (95%CI 1.5–2.1) and 3.9 (95%CI 3.3–4.5), relative to the eastern rural area, respectively , preterm birth /LBW (14.8%) and pneumonia (11.9%) in the eastern rural area, congenital anomalies (26.0%), preterm birth /LBW (16.5%) and birth asphyxia (13.1%) in the central rural area, and pneumonia (20.8%), preterm birth /LBW (17.3%) and congenital anomalies (16.1%) in the western rural area. In the eastern rural area, birth asphyxia was the leading cause of infant deaths in 2010–2012, accounting for 15.6% of all deaths, and the contribution of birth asphyxia dropped to 10.2%, making it the 4th leading cause in 2016–2018. In the western rural area, the proportions of infant deaths due to congenital abnormalities increased from 13.4% in 2010–2012 to 16.1% in 2016–2018, making it the third leading cause in 2016–2018, the contribution of pneumonia was stable in this period, ranging between 19.3 and 20.8% during the study period (Table p < 0.001). The main cause of infant deaths in the eastern and western rural areas decreased at AADRs greater than 10%, and there was no significant difference in AADRs between the eastern and central rural areas. In the western rural area, the reduction in mortality due to congenital abnormalities 4.2% (95%CI 2.5–5.9), prematurity/LBW 9.1% (95%CI 7.7–10.5) and pneumonia 6.6% (95%CI 5.0–8.1) was particularly slow  and 1.9 (95%CI 1.4–2.6) in the central rural area and between 1.7 (95%CI 1.5–2.1) and 26.9 (95%CI 9.7–95.5) in the western rural area in 2016–2018. The gap in infant mortality rate between the eastern and central rural areas widened for congenital abnormalities, preterm birth /LBW and birth asphyxia, and between the eastern and western rural areas widened for congenital abnormalities, preterm birth /LBW and pneumonia in 2010–2018. The RRs of the main cause-specific infant mortality rates showed no significant variation between the eastern and central rural areas in 2010–2018. The relative risks of infant mortality rates due to preterm birth /LBW, birth asphyxia and pneumonia between the eastern and western rural areas significantly increased over the study period , followed by the eastern rural area (from 30.0% in 2010–2012 to 53.7% in 2016–2018) and western rural area (from 25.4% in 2010–2012 to 40.0% in 2016–2018). The proportion of children who did not receive any medical attention still showed a large difference   in rural China, with an increase of 748% over the past decade . ImplemeHowever, there are still large regional differences in IMRs in rural China in 2010–2018. Relative to the eastern rural area, the RR of IMR in the central rural area remained at 1.4–1.6, while the RR in the western rural area increased from 2.4 to 3.1 during the study period. Socioeconomic factors are repeatedly considered to be strong determinants of population health, especially for infants . For exaAlmost half of all infant deaths (57.6%) occurred in the least developed western rural area during the study period. The leading cause of infant deaths was pneumonia, which is similar to that in other low-income regions . MeanwhiThere are some limitations in this study. First, we did not have data on factors related to infant deaths, such as household income, maternal education level and age, which prevented us from exploring the relationship between these factors and the infant mortality rate. Second, we did not collect data on health care services for the whole population. Thus, our analysis was based on the health care provided to infants before their death and our results regarding health care accessibility were biased.With the joint efforts of the country’s rapid economic growth and policies and programs to eliminate poverty and improve child health, the infant mortality rate dropped significantly in rural China from 2010 to 2018. However, great geographical disparities in IMR still persist in rural China. Almost half of infant deaths occurred in the least developed western rural area during the study period, and IMR in the western rural area was two to three times higher than that in the eastern rural area. Pneumonia and preterm birth /LBW were the main causes of infant deaths in the western rural area and were more prevalent than those in other areas. Therefore, expansion of public health policies, capital investment, health education, and access to medical resources should be a priority for reducing infant mortality rate in the western rural area.


Ixodes ricinus (90.0%), Ixodes hexagonus (7.3%), Dermacentor reticulatus (2.8%) and Rhipicephalus sanguineus (0.1%). Ixodes ricinus was the tick with the most divergent pathogens: Anaplasma sp. (1.3%), Babesia sp. (0.8%), Borrelia spp. (4.8%), Neoehrlichia sp. (3.7%) and Rickettsia helvetica (12.6%). In I. hexagonus, R. helvetica (1.8%) and Babesia sp. (0.6%) were detected and Rickettsia raoultii in D. reticulatus (16.2%). One of the two nymphs of R. sanguineus was co-infected with Borrelia and R. helvetica and the other one was uninfected. The high numbers of different pathogens found in this study suggest that companion animals, by definition synanthropic animals, and their ticks can serve as sentinels for emerging tick-borne pathogens.Ticks are vectors for many pathogens of veterinary and medical interest. In order to monitor ticks and tick-borne pathogens, the “Tekenscanner” (Dutch for Tick scanner), a citizen science project, was launched in The Netherlands. It is a smartphone application for pet-owners to get ticks from their dog or cat, identified and checked for pathogens for free. At the same time, information about the pet and the geographic location of tick infestation becomes available for research. The application was launched in 2018, and the results of the first 6 months after launch of the app were reported. Ticks were identified based on morphology, and DNA was extracted and amplified by a panel of tick-borne pathogen-specific primers. Next, the amplicons were subjected to reverse line blot with specific probes for important pathogens to determine their presence or absence. The present paper describes the results of 2019 and 2020. There were 2260 ticks collected from 871 dogs and 255 cats (26 ticks were from an unknown host) and all pet owners were informed about the results. Four species of ticks were collected: The online version contains supplementary material available at 10.1007/s00436-022-07518-3. Babesia, Borrelia and Anaplasma species is well described  were analysed . Rickettsia helvetica DNA (8.4%) was detected most frequently in I. ricinus from both cats and dogs, next to DNA of several Babesia and Borrelia species. In Dermacentor reticulatus the pathogen Rickettsia raoultii (13.3%) was found most often.To involve pet-owners in the collection of ticks from their pets, the “Tekenscanner” (Dutch for Tick scanner) smartphone application, funded by Bayer was launched in 2018 in the Netherlands  was noticed in the primer that was used in 2018 and 2019. All PCRs were performed using Phusion U green multiplex PCR master mix (ThermoScientific) with the following conditions for all reactions: after an initial denaturation at 98 °C for 30 s, 10 cycles of 98 °C (10 s), 64 to 55 °C (30 s) and 72 °C (15 s) were performed, in which the annealing temperature decreased with 1 °C in each cycle. Finally, 49 cycles with annealing temperature of 54 °C were performed with a final extension of 72 °C step for 7 min. PCRs for Babesia/Theileria and Anaplasma/Ehrlichia/Rickettsia were performed as multiplex, whereas the Borrelia PCR was performed separately. Prior to the RLB hybridisation, the two PCR products from the same tick were combined and RLB was performed as described  were performed as described using the same primers and probes  and sent to Baseclear  for Sanger sequencing in both directions with the same primers as used for PCR. Sequences were aligned in SeqMan Pro 14 (DNASTAR lasergene v16) and blasted (BLASTn) against the non-redundant nucleotide collection (nr/nt) at NCBI.Over the study period, 2286 ticks were recovered from 871 dogs, 255 cats and 22 unknown hosts and DNA of 16 pathogens was detected.I. ricinus (90.0%), Ixodes hexagonus (7.3%), D. reticulatus (2.8%) and Rhipicephalus sanguineus (0.1%) during the study period. From dogs and cats, in total respectively 1545 and 485 I. ricinus ticks were identified and all stages were found. There were 166 I. hexagonus ticks analysed. No I. hexagonus males were found. Dermacentor reticulatus ticks were almost exclusively found on dogs (57/64) and most of them came from the South-Western part of the country  from 686 dogs (1375 ticks), 201 cats (501 ticks) and 22 unreported hosts (26 ticks) were received in 2019 . Rickettsia raoultii was found once in an adult male from a dog and one female tick from a dog yielded a PCR product that hybridised with the catch-all probe for Rickettsia, but with none of the Rickettsia species specific probes. Sequencing and blasting of the PCR product gave 93% identity with Rickettsia monacensis (accession number MH618378). Neoehrlichia mikurensis was found in ticks from dogs and cats but was significantly (p < 0.001) more abundant in ticks from dogs (4.5%) than from cats (1.0%). Borrelia spp. were found in 4.7% of I. ricinus ticks with Borrelia garinii, Borrelia valaisiana and Borrelia afzelii, as the most abundant species in both cats and dogs. With the borrelia primer containing the unintended insertion, 5.2% of the I. ricinus ticks were positive for Borrelia spp. Using the new primer, resulted in a lower proportion Borrelia positive I. ricinus ticks (2.6%). Anaplasma phagocytophilum was found in 26 ticks (1.3%), see Table I. ricinus ticks (0.8%) contained Babesia DNA of which the majority was B. divergens (n = 11).Pathogens were detected in 21.4% of ks Table  and in 2I. hexagonus ticks  and one nymph from a cat (1.2%) contained R. helvetica (1.9%) and one nymph from a dog contained Babesia canis (4.3%).In only four D. reticulatus ticks (16.1%) were infected with R. raoultii  was the predominant tick species just as it was in 2018, the first year of the “tekenscanner” project  with more ticks removed from cats than from dogs. The contribution of D. reticulatus was also very similar, 2.4% and 2.8% for 2018 and 2019/2020, respectively, with more ticks from dogs than from cats. There were four R. sanguineus ticks collected in 2018 and two in 2019/2020, all removed from dogs. The four R. sanguineus ticks collected in 2018 were all outside The Netherlands , and one of the two R. sanguineus ticks from 2019/2020 was also collected abroad (France) and did not contained pathogens. It is not known whether the dog on which the other R. sanguineus tick (infected with B. afzelli and R. helvetica) was found has been abroad short before collection. Analysis of the differences in the presence of pathogens in ticks of 2018 with 2019/2020 is not possible, because in 2018 ticks from the same species and host were pooled for analysis and ticks were collected only over a 6-month period.In 2019 and 2020, there were in total 2286 ticks collected and in 454 ticks (19.9%) pathogens were detected. Due to covid-19 measures in 2020 the number of collected ticks was much lower. I. ricinus and this tick species was more often infected with TBPs (21.4%), whereas in only 6.5% of the ticks from other species pathogen DNA could be detected.The most frequently sent in B. burgdorferi s.l. complex, the causative agent of Lyme borreliosis, were exclusively found in I. ricinus ticks, just like in 2018  is of medical importance. We detected six species of the B. burgdorferi s.l. complex and the most abundant Borrelia species were B. garinii, B. valaisiana and B. afzelli in that order, B. burgdorferi s.s. was also detected. Borrelia afzelli, B. garinii and Borrelia burgdorferi s.s. were considered the most common species in dogs and man in Europe  symptoms in humans and has been involved in perimyocarditis and meningitis  rickettsiae and can cause human tick-borne lymphadenopathy (TIBOLA) Below is the link to the electronic supplementary material.


For the in vitro study a six-species supragingival biofilm model containing A. oris, V. dispar, C. albicans, F. nucleatum, S. mutans and S. oralis was used. Biofilms were grown anaerobically on hydroxyapatite discs and treated with natural mouthrinses Ratanhia, Trybol and Tebodont. 0.9% NaCl and 10% ethanol served as negative controls, while 0.2% CHX served as positive control. After 64h hours, biofilms were harvested and quantified by cultural analysis CFU. For the in situ study, individual test splints were manufactured for the participants. After 2h and 72h the biofilm-covered samples were removed and treated with the mouthrinses and controls mentioned above. The biofilms were quantified by CFU and stained for vitality under the confocal laser scanning microscope. In the in vitro study, 0.2% CHX yielded the highest antimicrobial effect. Among all mouthrinses, Tebodont  compared with 0.9% NaCl showed the highest antimicrobial potential. After 72h there was no significant reduction in CFU after 0.2% CHX treatment. Only Trybol showed a statistically significant reduction of aerobic growth of microorganisms in situ . After treatment with the positive control 0.2% CHX, a significant percentage of non-vital bacteria  was detected. To sum up, a less pronounced effect of all mouthrinses was shown for the in situ biofilms compared to the in vitro biofilms.For centuries, diverse mouthrinses have been applied for medicinal purposes in the oral cavity. In view of the growing resistance of oral microorganisms against conventional antimicrobial agents e.g. chlorhexidine, the implementation of alternative treatments inspired by nature has lately gained increasing interest. The aim of the present study was to compare  The microbial cells, which are embedded in a matrix of extracellular polymeric substances, are irreversibly attached to epithelial- and tooth surfaces. Despite the dominance of adverse conditions  in the microenvironment of the oral cavity, biofilms survive thanks to commensal or mutualistic symbiotic relationships among different microbial species, allowing for the harmonic growth of both aerobic and anaerobic microorganisms . This ph studies . One of  studies . The inibiofilms . Furtherbiofilms , examinem models . The aim22.12.1.1Veillonella dispar (OMZ 493), Fusobacterium nucleatum (OMZ 598), Streptococcus oralis (OMZ 607), Streptococcus mutans (OMZ 918), Actinomyces oris (OMZ 745) and Candida albicans (OMZ 110) The microorganisms were obtained by cultivation on Columbia blood agar plates  supplemented with 5% (v/v) hemolyzed human blood under anaerobic conditions at 37°C. For overnight cultures, the microorganisms were picked from the CBA plates and inoculated into 9 ml filter-sterilized fluid universal medium + 0.3% glucose supplemented with 67 mmol/L Sørensen’s buffer, pH 7.2 . As nutrition for V. dispar, 0.1% (v/v) sodium lactate was added into mFUM (550) was measured for each strain and adjusted with fresh mFUM at 1.0 +/- 0.05. To obtain a microbial suspension the density-adjusted culture was mixed in equal volume.For this study, the following six representative supragingival microorganisms were used: nto mFUM . The cul2.1.2The saliva was collected in the morning between 9:00 and 10:00 o’clock, at least 1.5 h after eating, drinking or plaque control. Whole, unstimulated saliva was collected in sterile 50 ml tubes. Afterwards the collected saliva was pooled and centrifuged . The supernatant was pasteurized  and again centrifuged . The supernatant was pipetted into 50 ml sterile tubes and stored at -20°C. For pellicle formation the hydroxyapatite discs  were placed in 24-well polystyrene cell culture plates and covered with 800 µl of processed whole unstimulated pooled saliva from individual donors .2.1.3Biofilms were grown in 24-well polystyrene cell culture plates on pellicle coated HA discs for 64 h under anaerobic conditions at 37°C to initiate the biofilm formation. For the first 16 h, 1120 µl of saliva (diluted 1:2 with 0.25% NaCl), 480 µl mFum (Fum + 0.3% glucose) and 200 µl of the prepared microbial suspension were added to the preconditioned pellicle-coated discs. The growth medium consisting of diluted saliva and mFUM with a carbohydrate concentration of 0.15% glucose and 0.15% sucrose (w/v) instead of 0.3% glucose was renewed after 16 h and 40 h, respectively. The 1-minute treatments with three different mouthrinses Table 1 2.1.4in vitro and in situ supragingival biofilms, Ratanhia and Trybol were diluted as recommended in the application instructions. Ratanhia was diluted to obtain final alcohol concentration of 10%, while Trybol was diluted with sterile water (1:20). All three of the chosen antimicrobial agents consist mainly of essential oils, as specified in 2.1.52) and anaerobic conditions.After 64 h the biofilms were rinsed three times in 0.9% NaCl to remove the non-adherent microorganisms. To harvest the biofilms, discs were transferred into 1 ml 0.9% NaCl, vortexed for 2 min and then sonicated for 5 s at 30 W . The resulting microbial suspensions were diluted in 0.9% NaCl by serial dilutions and plated on selective  and non-selective agar plates (CBA) to assess the colony forming units (CFU). The plates were incubated for 72h under both aerobic (10% CO2.22.2.1Six volunteers from 25 to 59 years of age were selected. Prerequisites for participation in the study included (i) no use of antibiotics and mouthrinses three months prior to the wearing, (ii) no pregnancy or breastfeeding, (iii) no systemic diseases, and in addition, (iv) no oral hygiene was carried out in the 2 hours before wearing the appliance, (v) the consumption of food and liquids, as well as alcohol and nicotine, was prohibited during wearing the appliances and finally, (vi) the subjects had not participated in any other clinical examination up to 30 days before the start of the study. The written consent of the test persons to participate was given. The study was approved by the Ethics Committee of the University of Zurich (Basec-Number 2019-01324). After screening the patients’ dental health, the DMFT scores retrieved were between 0 and 13.2.2.2The bovine enamel slabs  were gained from freshly extracted bovine spongiform encephalopathy-free teeth. For each volunteer an individual, intraoral splint system was constructed for the upper jaw 2.32) and anaerobic conditions.The colony-forming units (CFUs) for 2h and 72h were evaluated quantitatively. The patients had to wear the splint system first for 1 min, then the BES were treated for 1 min with the mouthrinse and control solutions respectively. After that the discs were rinsed three times in 1 ml 0.9% NaCl. Subsequently, the BES were worn for 2h and 72h, respectively. After the removal of the splints from the oral cavity, the silicon was detached from the samples and the discs were then treated for 2 min with the mouthrinses and again dipped in 1 ml NaCl three times. Afterwards the discs were transferred in 1 ml 0.9% NaCl. To harvest the biofilms, the BES were vortexed for 30 sec, sonicated for 2 min and again vortexed for another 30 sec. From the resulting microbial suspensions, serial dilutions were done and plated on CBA. The plates were incubated for 72h under aerobic .The obtained biofilms on the BES after 72 h were stained using nucleic acid stains. Following dyes from Invitrogen™  were used for viability analysis and visualization of extracellular DNA (eDNA): SYTO 40 a cell-permeant nucleic acid stain, DRAQ7 and TOTO-1 cell impermeable DNA dyes. The BES were stained for 15 min at room temperature in the dark with a final concentration of 20 µM for SYTO 40 and DRAQ7 and 2 µM for TOTO-1. After staining, the discs were washed with H2.52.Subsequently, the stained biofilms were analyzed by confocal laser scanning microscopy using a Leica TCS SP5 microscope  with x 63/1.4 NA oil-immersion objective lens. Excitation of the dyes were carried out using the following wavelengths: UV laser 405 nm, Argon laser 488 nm and Helium-Neon laser 633 nm. Fluorescence emission was detected at the following wavelengths: 420-460 nm (SYTO 40), 515-570 nm (TOTO-1), and 687-770 nm (DRAQ7). The biofilms were scanned in sequential mode, and z-series were generated by vertical optical sectioning using a step size of 0.5 µm. Image acquisition was conducted in 6x line average mode. Each disc was measured at three different positions. Images were processed using IMARIS software  and quantified by Fiji. The 3D data were collapsed into 2D by maximal z-projection and each channel was analyzed separately. Contrary to TOTO-1, the threshold of SYTO 40 and DRAQ7 stains was not modified. The measurements were set areas, min/max, gray value, area fraction, mean gray value and stack position and the size of the analyze particles were from 0.10 - infinity micron2.6in vitro study three independent experiments were conducted and within each experiment every treatment group was represented in triplicate (n=9). For the in situ study independent experiments of 6 subjects were carried out and within each subject every treatment group was represented once. The data points of the treatment groups were summarized of all subjects (n=6). For the quantification of the cell viability, 18 data points were generated, as each biofilm sample was scanned at 3 positions. Two-way analysis of variance (ANOVA) was used to analyze the difference in microbial growth per biofilm between the control groups  and the different treatments with herbal mouthrinses. For correction Tukey’s multiple comparisons test was used. Missing values were ascribed the lowest detection limit value of the assay to allow for logarithmic transformation. Statistics have been implemented using GraphPad Prism software . Significance level was set at p < 0.05.For the 33.1in vitro is illustrated In 10 CFU, median 0.000, p< 0.0001) on both aerobic and anaerobic microorganisms compared to the two negative controls . A significant antimicrobial effect was also found for Tebodont  compared to the negative controls (0.9% NaCl and 10% EtOH). In comparison with Trybol  and Ratanhia , Tebodont presented a significant antimicrobial activity. Treatment with Ratanhia  or Trybol  failed to yield significant reduction of log10 CFU compared to the negative controls.The antimicrobial effect of the tested mouthrinses on the microbial growth of supragingival biofilms consisting of six species grown for 64h A. oris , V. dispar  and F. nucleatum . A substantial antibacterial effect of Tebodont was observed for S. mutans  and S. oralis . The microbial counts of Candida albicans solely  were not affected by the treatment with the herbal mouthrinses. Treatment with 0.2% CHX ended to a significant decrease of microbial counts of all six supragingival species .Furthermore, Tebodont induced a significant decrease of the bacterial counts of 3.2in situ biofilms with different herbal mouthrinses are shown in 10 CFU, median 1.534) and anaerobic  microorganisms after 2h. In contrast, Tebodont, showed no killing effect in situ . Contrary to Tebodont, a significant reduction of the microbial counts was detected for Trybol under both aerobic  and anaerobic conditions .The eradication rates of initially adherent oral aerobic and anaerobic microorganisms following treatment of in situ (10/mm2) after treatment with 0.2 CHX . In comparison to Tebodont, only Trybol showed a statistically significant difference in CFU (log10/mm2) of aerobic microorganisms in situ . Interestingly, there was no significant difference between the negative controls 0.9% NaCl ,10% ethanol  compared to the positive control (0.2% CHX) as shown in Regarding the adherent oral microorganisms after 72h in situ Figure 43.3in vitro and in situ biofilms (72 h) in regard to the antimicrobial effects of the tested herbal mouthrinses is demonstrated in in vitro versus in situ, a significant CFU reduction was shown after treatment of the in vitro biofilms with 0.2% CHX  or Tebodont . Yet, no significant reduction of the microbial growth for both aerobic and anaerobic microorganisms was found after treatment of the in situ biofilms (72h) with 0.2% CHX  or Tebodont . Interestingly, treatment with the mouthrinse Ratanhia led to a less substantial microbial growth  in situ after 72 h  when compared with the in vitro microbial growth . However, the mouthrinse Trybol yielded no significant reduction in both aerobic and anaerobic microbial growth both after 72 h in situ  and in vitro .An interesting difference between 3.410 CFU, median 42.150) significantly increased the proportions of the dead cells compared with the negative control groups 0.9% NaCl  and 10% ethanol .The quantification of stained nucleic acids following CLSM microscopy is shown in 10 CFU, median 23.650, p< 0.0015) and Tebodont  yielded higher proportions of vital microorganisms compared to CHX . The mouthrinse Trybol yielded for both SYTO 40 and DRAQ7 a high variance in the percentages of stained nucleic acids. Yet, when Trybol was compared with both SYTO 40  and DRAQ7  compared to the negative control (0.9% NaCl) there is no statistically significant difference.Treatment with the herbal mouthrinses as Ratanhia  images of biofilms after antimicrobial treatment are shown in 4in vitro biofilms versus in situ biofilms. This allowed a better understanding of the differences in the outcomes between in vitro and in situ biofilms after treatment with plant-derived antimicrobial agents.Nowadays, the use of a toothbrush and fluoridated toothpaste is essential when oral hygiene is practiced. However, complete plaque removal is rather unrealistic, so a chemotherapeutic approach could be beneficial in some cases, in which antimicrobial control is mandatory . The preIn vitro studies are necessary to evaluate the effectiveness of specific antimicrobial agents and to collect useful information for further in situ studies . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.NS conducted the experiments, analyzed the data, and wrote this manuscript. PP wrote the application for the Ethics Committee. PP and TA critically reviewed the manuscript. LK and TT conceived the idea for this manuscript, were involved in the data analysis and critically reviewed the manuscript. All authors contributed to the article and approved the submitted version.