Objective: To evaluate the efficacy of primary intra vitreal bevacizumab (IVB) injection on macular edema in diabetic patients with improvement in best corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography (OCT).Methods: This prospective interventional case series study was conducted at Retina Clinic, Al-Ibrahim Eye Hospital, and Isra Postgraduate Institute of Ophthalmology Karachi. Between December 2010 to June 2012. BCVA measurement with Early Treatment in Diabetic Retinopathy Study (ETDRS) charts and ophthalmic examination, including Slit-lamp bio microscopy, indirect ophthalmoscopy, Fundus fluorescein angiography (FFA) and OCT were done at the base line examination. At monthly interval all patients were treated with 3 injections of 0.05 ml intra vitreal injection containing 1.25 mg bevacizumab. Patients were followed up for 6 months and BCVA and OCT were taken at the final visit at 6 month.Results: The mean BCVA at base line was 0.42±0.14 Log Mar units. This improved to 0.34±0.13, 0.25±0.12, 0.17±0.12 and 0.16±0.14 Log Mar units at 1 month after 1st, 2nd 3rd injections and at final visit at 6 months respectively, a difference that was statistically significant (P>0.0001) from base line. The mean 1mm CMT measurement was 452.9 ± 143.1 µm at base line, improving to 279.8 ± 65.2 µm (P<0.0001) on final visit. No serious complications were observed.Conclusions: Primary IVB at a dose of 1.25 mg on monthly interval seems to provide stability and improvement in BCVA and CMT in patient with DME. A study carried out at Al Ibrahim Eye Hospital (2011) showed that 39.8% of patients registered at retinal clinic were suffering from DR, out of which 45% were having Clinically Significant Macular Edema (CSME).5With the increasing prevalence of diabetes in the world wide, Diabetic retinopathy (DR) remains the major threat to sight in the working-age population. It remains as a major cause of blindness in developing countries.6 In ocular vascular disease such as DME, VEGF levels has been found considerably higher in macular region.7 The Early Treatment Diabetic Retinopathy (ETDRS) shows 3-year risk of moderate visual loss due to macular edema was 32%, and focal macular laser photocoagulation was effective in the treatment of DME. ETDRS demonstrated that immediate focal laser photocoagulation reduced the risk of moderate visual loss by 50% . However, 12% of treated eyes still lost ≥ 15 ETDRS letters at 3-year follow-up interval. Furthermore, only 3% of laser-treated eyes experienced a gain of ≥ 3 lines of vision.8 The failure of laser photocoagulation in these eyes has prompted interest in other treatment modalities such as Anti-VEGF agents9, intravitreal triemcinolon acetonide (IVTA),10 pars plana vitrectomy (PPV)11 or treatment with protein Kinase C inhibitors.12Retinal hypoxia is the primary cause of DR which increases the expression of vascular endothelial growth factor (VEGF). It is an endothelial cell-specific mitogen which induces angiogenesis and increase vascular permeability by affecting endothelial tight-junction protein.13 vascular permeability and neovascularization secondary to age-related macular degeneration (AMD).14Food and Drug Administration (FDA) has approved bevacizumab  a fusion protein with human antibody backbone against VEGF, it binds and inhibits all the active forms of VEGF and is used in the treatment of metastatic colorectal cancer. Some studies had found it useful in the reduction of macular edema secondary to central retinal vein Occlusion (CRVO),st injection.The purpose of this study was to evaluate the best corrected visual acuity (BCVA) measured on ETDRS chart and central macular thickness (CMT) carried out on optical coherence tomography (OCT) after a series of 3 injection of IVB at interval of one month and at mean follow up of 6 months after 1All patients were followed up for 6 months. Approval of the study was obtained from the institutional ethical committee, and informed consent was obtained from all patients. The study followed the principles of Declaration of Helsinki. Patients with evidence of DME were included in this study. DME is defined as the evidence of diffuse retinal thickening, hard exudates (with out a circinate ring pattern) involving the center of the macula , or both and Diffuse fluorescin leakage involving the center of the macula on FFA, and Central Macular Thickening (CMT) on Optical Coherence Tomography (OCT).The exclusion criteria included patients with DME who had been treated previously with laser photocoagulation, intra vitreal triamcinolone or any Anti-VEGF therapy elsewhere. The patients with Macular ischemia, uncontrolled intraocular pressure, intra ocular surgery within past 6 months, history of vitreo retinal surgery of the study eye, or any evidence of epiretinal membrane or vitreomacular traction were excluded.After detailed history each patient underwent baseline examination which included BCVA measurement with ETDRS charts and ophthalmic examination, including slit lamp bio microscopy and dilated fundus examination with +90 diopter lens and indirect ophthalmoscopy. All patients had fundus fluorescien angiography (FFA).Baseline CMT was analyzed by OCT using 6 diagonal slow 6mm radial line scan on Topcon analyzer .Procedure: All eyes had several drops of local anesthetic  with dilatation of pupil  before the procedure. After the eye had been prepped in standard fashion using 5% povidoniodine, an eye lid speculum was used to stabilize the eyelids and the injection of 1.25 mg (0.05 ml), bevacizumab was performed at 3.5 to 4mm posterior to the limbus through the inferiotemporal pars plana with a tuberculin syringe and 30 gauge needle After injection, retinal artery perfusion was checked with the indirect ophthalmoscopy. A single drop of antibiotic  is instilled and patients were instructed to administer topical antibiotics for one week.st month visit BCVA was recorded and 2nd injection was administered and the same was repeated after one month and the 3rd injection was administered .The patients were followed-up for 6 months and final BCVA and CMT were taken at the final visit at 6 month after the first injection.All patients were examined at one week and one month after the first injection. At 1st injection of bevacizumab were included for analysis. The patients had a mean age of 53.5 ± 11.4 years, and 25(59.52%) were male, 17(40.47%) were female.A total of 49 diabetic patients were enrolled in this study. Seven of our patients were lost the follow-up or were excluded due to exclusion criteria from the study. The final data of 78 eyes of 42 patients with a minimum follow up of 6 months after 1st injection BCVA improved to 0.34±0.13 Log Mar unit, a difference that was statistically significant (P<0.0001). This improvement in BCVA was maintained after 2nd and 3rd injections which were 0.25±0.12 Log Mar units and 0.17±0.12 Log Mar units respectively. In addition the mean BCVA at 6 month follow up examination was 20/25 (0.16±0.14 Log Mar units), a statistically significant difference from baseline BCVA (P<0.0001)..st injection, 49(62.8%) eyes improved one or more ETDRS line of BCVA,27(34.6%) eyes remained stable and 2(2.5%) decreased one or more ETDRS lines of BCVA. This trend continued after 2nd and 3rd injection, and at 6 month follow up examination, 16(20.5%) eyes remained stable, 57(73.0%) eyes improved one or more ETDRS lines and 5(6.4%) eyes had decreased one or more ETDRS lines of BCVA. .A mild anterior chamber cellular reaction was observed in 9 (11.5%) eyes, but the condition improved with use of topical corticosteroid and antibiotic combination drops . No other injection or drug related complications were observed.st injection and continued throughout the study period.  injection has some promising results but this treatment modality is not without its risks and complication.10 These complications were related to the injection procedure or to the corticosteroid suspension.15 Oral protein Kinase C inhibitors had demonstrated efficacy in prevention of visual loss from DME.12 Currently Fluocinolon Acetonide vitreous inserts are under investigations showing some promising results.16Several treatment methods for DME are under investigation. ETDRS has demonstrated that, the risk of visual loss from DME can be reduced by laser photocoagulation.13, AMD14 and Proliferative Diabetic Retinopathy (PDR).17 As VEGF disrupts the inner blood-retinal barrier and causes exravasation of fluids by affecting endothelial tight junctions. Therefore, VEGF inhibition by IVB has been emerged as a target molecule for the treatment of DME.The important role of VEGF in the breakdown of the blood-retinal barrier and vascular permeability resulting in retinal edema is clear. Therefore, the rationale for use of anti-VEGF agents for treatment of DME is significant. Bevacizumab  is a fusion protein with human antibody backbone that binds to all sub types of VEGF and used successfully in tumor therapy as a systemic drug. Recently off label use of IVB injection has been presented in small cohorts of patients with macular edema from various causes like CRVO18 published a report of 26 eyes, followed up for 3 months after IVB injection. The mean BCVA at baseline 0.726 Log Mar was improved to 0.452 Log Mar at 3rd month. Flourescien leakage stopped in 25 (96.15%) eyes. Kumar and Sinah19 reported results of 20 eyes with DDME treated with IVB at a dose of 1.25mg that had not responded to previous photocoagulation. They concluded that IVB resulted in a significant decrease in macular thickness and improvement in BCVA at 3 month. Ozkiris A20 presented results of 30 eyes, out of which 24 (80%) eyes showed increased visual acuity after mean, follow up time of 5.6 months after IVB injection. BCVA improved from 1.09±0.23 Log Mar (at baseline) to 0.90±0.17 Log Mar at 1st month and 0.77±0.26 Log Mar at the last visit. The mean edema map values significantly decreased by 33.3%. Arevalo et al21 published a report of 24-month anatomic and visual acuity response after primary intravitreal bevacizumab in patients with Diffuse Diabetic Macular Edema (DDME). They compared 2 different doses of intravitreal bevacizumab, 1.25mg and 2.5 mg respectively. They found that primary IVB at doses of 1.25 or 2.5 mg seem to provide stability and improvement in BCVA, OCT, and FA results in DME at 24 months.There are several studies in the literature on the intravitreal administration of anti-VEGF for DME. Recently Khan et alst IVB injection. A further improvement was achieved after each injection of bevacizumab and was maintained at 6 months follow up. BCVA in our study improved from 0.42±0.14 Log Mar unit at base line to mean 0.34±0.13 Log Mar unit after one month of 1st IVB injection and further improvement to 0.25±0.12 Log Mar unit after one month of 2nd injection and this trend continued to the final visit at 6 month with BCVA improving to 0.16±0.14 Log Mar unit. The mean central 1mm CMT improved from 452.9±143.1 µm at base line to 279.8±65.2 µm at 6 month visit. This confirms the finding of previous studies which shows that the eyes with DME treated with IVB result in both anatomic and functional improvement.The results of our study compare favorably with these reports and confirm their findings. In our study, we found that improvement in BCVA was achieved within a month after 1The results of our and other above mentioned studies indicate that IVB injection may have a beneficial effect on macular thickness and BCVA in DME. In future this new treatment method may replace or compliment focal or grid laser photocoagulation.Our study has some limitations. First, the follow up time was relatively short, but visual and anatomical responses were apparent during the follow-up time. Second, there is no control group in this study as randomization was not possible. Third, this study was carried out in a single center so results cannot be generalized.This study demonstrated that IVB injection is an effective approach with promising results for the primary treatment of DME. IVB at a dose of 1.25mg on at least monthly interval seems to provide stability and improvement in BCVA and CMT in DME at 6 moths. However evaluation in a multicenter, randomized, controlled clinical trial comparing IVB with other treatment modalities is needed to evaluate the safety and efficacy of this treatment method.IT: Conceived and designed the protocol, did data collection and statistical analysis, manuscript writing and editing.AR: was involved in clinical management of patients.P.SM and SM: Critically reviewed the manuscript for final publication.


Dear Sir, In boys precocious puberty is defined as the development of secondary sexual characters before 9 year of age. In girls, the development of breasts (thelarche) before 7.5 year, the development of pubic hairs (pubarche) before 8.5 year or menarche before the age of 9.5 year is considered precocious [1]. Hypothyroidism is usually associated with delayed puberty and rarely with precocious puberty [2]. Hypothyroidism with precocious puberty was first described by Kendle in 1905 [3]. Van Wyck and Grumbach reported the association of multi-cystic ovaries with hypothyroidism and precocious puberty [4]. This pathology is more frequently seen in girls. Precocious puberty is always isosexual and characterized by breast enlargement, multicystic ovaries and menstrual bleeding. In boys it may be associated with testicular enlargement and minimal penile enlargement. Herein we report a case of Van Wyk-Grumbach Syndrome.An 8 year-old-girl with cyclical menstrual bleeding was referred to us from gynecological department for surgical management of bilateral cystic ovaries detected on ultrasound. There were 10cm x 5cm cyst in right ovary and 2cm x1.5cm cyst in the left ovary. The girl was having cyclical monthly menstrual bleeding (up to 4 days) for the last seven months. It was not associated with abdominal pain, vomiting, hematuria or per rectal bleeding. On general physical examination she was a normal looking girl, relatively short statured but well oriented. Her weight was 30 kg (75th percentile) and height 114 cm (less than 5th percentile). Her head circumference was 52 cm and mid arm circumference was 20 cm. Her vitals were normal. She was anemic. On perineal examination, external genitalia were normal. Breast development was at tanner stage III and pubic hair development at tanner stage II. Abdomen was protuberant. Neurological and ophthalmic examinations were normal.Investigations revealed Hb 10.2 gm %, serum estradiol < 20.00pg/ml, T3 0.260 pgm/ml (range 2-4.4), T4 0.139 ngm/dl (range 0.93-1.7), TSH 785 mIU/ml (range 0.27- 4.2), LH 4.0 mIU/ml, FSH 6.45mIU and prolactin level was 11.2 micro gm/l (range 10.8-12.6). After investigations due to markedly increased TSH level, diagnosis of “TSH induced precocious puberty” was made and oral levothyroxine was started at the dose of 150 ugm/day. Ultrasound of abdomen repeated after 15 days showed multiple cysts in the right ovary with larger one of 8cm x 4cm. Left ovary was normal. The patient was followed on medicine for 6 months. The menarche stopped, height increased and protuberant abdomen became normal. At nine months follow-up, thyroid profile was within normal range. On ultrasound scan the left ovary was normal while on right side there was a small cyst. At last follow up her weight has reduced to 24 kg and height increased up to 124.5cm. She is currently on levothyroxine 50 microgram per day.Van Wyck and Grumbach proposed an overlap in negative feedback regulation with over production of gonadotropins as well as thyrotropins  in response to thyroid deficiency [2]. Later it has been observed that GnRH is unresponsive or bionegative and precocious signs are due to thyrotropins. Follicle stimulating hormone theory postulated that high levels of TSH interacts with FSH receptors, inducing FSH like effects on the gonads resulting in multicystic ovaries, menstrual bleeding and breast enlargement. In our patient, TSH was markedly elevated and precocious features were present. Children with precocious puberty due to other etiologies are tall, have pubertal growth spurt and advanced bone age where as children with hypothyroidism are short statured, have delayed bone age and there is no concomitant growth spurt. Treatment of precocious puberty due to hypothyroidism is simply orally levothyroxine.Source of Support: NilConflict of Interest: None declared


Dear Editor,Hepatitis C virus (HCV) with around 180 million infected patients worldwide is the leading cause of mortality and morbidity (1). The prevalence of HCV in Iran is about 0.2% . The study was based on the analysis of HCV genotype prevalence from 2003-2011. The results showed that in 2003, genotype 1a was the most common 47.8 %) and decreased over time (44.9 % in 2011). It was the same for genotype 1b. HCV genotype 3a was shown to be increased over time; in 2003 its prevalence was 30.1% which was increased up to 39.6% in 2011 , while the SVR shown by patients infected with genotype 3 was more than 80 % (


Tumor, is one of the major reason for human death, due to its widespread occurrence. Betulinic acid derivatives have attracted considerable attention as cancer chemopreventive agents and also as cancer therapeutics. Many of its derivatives inhibit the growth of human cancer cell lines by triggering apoptosis. With this background, we planned to synthesize a series of betulinic acid derivatives to assess their antiproliferation efficacy on human cancer cell lines.in vitro. The pharmacological results showed that some of the compounds displayed moderate to high levels of antitumor activities with most of new exhibiting higher inhibitory activities compared to BA. The IC50 values of compound 3c on the five cancer cell lines were 2.3, 4.6, 3.3, 3.6, and 4.3 μM, respectively. Subsequent fluorescence staining and flow cytometry analysis (FCM) indicated that compound 3c could induce apoptosis in MGC-803 and PC3 cell lines, and the apoptosis ratios reached the peak (37.38% and 33.74%) after 36 h of treatment at 10 μM.A series of novel betulinic acid derivatives were designed and synthesized as highlighted by the preliminary antitumor evaluation against MGC-803, PC3, A375, Bcap-37 and A431 human cancer cell lines This study suggests that most of betulinic acid derivatives could inhibit the growth of human cancer cell lines. Furthermore, compound 3c could induce apoptosis of cancer cells. Malignant neoplasm is the major cause of human death worldwide, mainly due to its high occurrence. Thousands of people die of cancer every year, despite aggressive treatment regimens including surgery, chemotherapy, radiation therapy, and palliative care. The situation demands urgent need for new therapies of therapeutic combinations to improve the survival and quality of life of cancer patients.Betulinic acid -en-28-oic acid 1) is a naturally occurring pentacyclic triterpenoid, Mostly in vitro. The results showed that some of the compounds displayed moderate to high levels of antitumor activities with most of new exhibiting more potent inhibitory activities compared to BA. The IC50 values of compound 3c with the five cancer cell lines were 2.3, 4.6, 3.3, 3.6, and 4.3 μM, respectively. Furthermore, experimental results of fluorescent staining and flow cytometry analysis (FCM) indicated that compound 3c could induce apoptosis in MGC-803 and PC3 cell lines to the extent 37.38% and 33.74% respectively after 36 h of treatment at 10 μM. These apoptosis ratios were more compared with the positive controls HCPT (Hydroxycamptothecin).In order to search for BA derivatives with high antitumor bioactivity, we performed herein synthesis of new pentacyclic triterpene derivatives, particularly those with substituents at the 28-COOH position. The antiproliferative activities of the derivatives were evaluated against MGC-803, PC3, A375, Bcap-37 and A431 cell lines using MTT (thiazolyl blue tetrazolium bromide) assay 2CO3 in DMF at room temperature to give the compounds 2a-2c with high yield. Then, the compounds 2a-2c were reacted with corresponding amines to give the nitrogen-containing derivatives 3a-3l, respectively , HCPT, and the compounds were dissolved in DMSO. ADM and HCPT were used as positive controls, and the negative control cells were treated with culture medium containing 0.1% DMSO. When the IC50 (BA derivatives) could not reach the highest concentration, > 20 μM was employed for our study. Each experiment was repeated at least three times. The results were summarized in Table The 50 values, 2.3, 4.6, 3.3, 3.6, and 4.3 μM, respectively). At the same time, it was found that active compounds showed antitumor activities against broader spectrum of tumors. Based on results we could summarize that the antiproliferative effect was significantly changed as the length of the carbon chain was increased (2 > 3 > 4), such as compounds 3a, 3e, and 3i. However, when the 28-COOH esterified with dibromoalkane, compounds 2a-2c had lower antitumor effects.As shown in Table In addition, the compounds containing acyl piperazine moiety at C-28 did not display higher inhibitory activity than the other, and some compounds only had moderate antitumor activities.It has been reported that BA and its derivatives induce apoptosis and growth inhibition in certain cancer cell lines,28. In tvia AO/EB staining.The morphologic changes in the cell after treatment with compound 3c were assessed by fluorescene microscopy after staining with AO/EB. AO permeates all cells and makes the nuclei appear green. EB is only taken up by cells when cytoplasmic membrane integrity is lost, and stains the nucleus with red and also dominates over AO. Thus live cells have a normal green nucleus; early apoptotic cells have bright green nucleus with condensed or fragmented chromatin; late apoptotic cells display condensed and fragmented orange chromatin; cells that died from direct necrosis have a structurally normal orange nucleus. With HCAs can be seen in Figure 3c at 5 μM on MGC-803 and PC3 cells from 12 to 48 h was detected via Hoechst 33258 staining.Hoechst 33258 is a hydrophilic and fluorescent probe only when bounded the DNA of cells, and live cells with uniformly light blue nuclei were treated with Hoechst 33258. The Hoe3c induced apoptosis against MGC-803 and PC3 cell lines. These results were identical with the previous AO/EB double staining.As can be seen in Figure via TUNEL assay.TUNEL is a common method for detecting DNA fragmentation that results from apoptotic signaling cascades. The assay relies on the presence of nicks in the DNA which can be identified by terminal deoxynucleotidyl transferase or TdT, an enzyme that can catalyze the addition of dUTPs that are secondarily labeled with a marker. It may also label cells that have suffered severe DNA damage. Under a fluorescence microscope, the cells were observed with brown precipitate were the result of positive apoptosis. With HCPT and BA as positive control at 10 μM for 48 h, the compound 3c at 5 μM against MGC-803 and PC3 cells from 12 to 48 h was detected As can be seen in Figure -/PI+), late apoptotic cells , intact cells  and early apoptotic cells [The apoptosis ratios induced by compound 3c in tumor cells were quantitatively assessed by FCM. In early apoptotic cells, phosphatidylserine (PS) which distributed inside the lipid bilayer in the normal cells was transferred from the inside of the cell membrane to the outside. Annexin V was a calcium-dependent phospholipid binding protein that has a high affinity for the phophatidylserine PS, a plasma membrane phospholipid, used to detect early apoptotic cells. PI (Propidine Iodide) is an intercalating agent and a fluorescent molecule with a molecular mass of 668.4 Da that can be used to stain cells that had lost membrane integrity. So, the different periods of apoptotic cells could be distinguished when Annexin V matched with PI: necrotic cells . As showin vitro. In our study, a series of BA derivatives were designed, synthesized and evaluated their antitumor activities against the MGC-803, PC3, A375, Bcap-37, and A431 cell lines. Our data suggest that the C-28 amino substituted BA derivatives possess stronger antiproliferative ability. Eight compounds  showed significant cell growth inhibition activity against the five cancer cell lines. The IC50 values of compound 3c against the five cancer cell lines were 2.3, 4.6, 3.3, 3.6, and 4.3 μM, respectively. However, the compounds containing an acyl piperazine moiety at C-28 did not display higher inhibitory activity, and some compounds only had moderate antitumor activity, but still more active than the parent BA.BA is an important natural product, and more and more studies have shown that BA has significant anticancer activity against various kinds of cell lines In addition, the apoptosis-inducing activity of compound 3c in MGC-803 and PC3 cell lines was investigated by following assays: AO/EB staining, Hoechst 33258 staining, TUNEL assay and FCM. The preliminary mechanistic studies indicated that the compound 3c may inhibit cell growth by inducing apoptosis. The apoptosis ratio reached 37.38% and 33.74% after 36 h of treatment at 10 μM, higher than the ratios observed for the positive control HCPT (27.49% and 23.53% respectively). These findings provide a very powerful incentive for further research on the chemical modification and structure-activity relationships of BA and other triterpenoid acids.1H-NMR and 13C-NMR were recorded using a JEOL-ECX500 spectrometer at 22°C, with tetramethylsilane as the internal standard and CDCl3 as the solvent. Column chromatography was performed using silica gel (200–300 meshes) BA with more than 98% purity was purchased from Zhejiang Tiancao Biotech Co., Ltd. Reagents of analytical grade were obtained from Yuda Chemistry Co., Ltd., and used without further purification unless otherwise noted. Infrared spectra were recorded on a Bruker VECTOR22 spectrometer in KBr disks. 2 at 37°C. All cell lines were maintained at 37°C in a humidified 5% carbon dioxide and 95% air incubator.MGC-803, PC3, A375, Bcap-37 and A431 cell lines were obtained from the Institute of Biochemistry and Cell Biology, China Academy of Science. MGC-803 is gastric cancer cell line, PC3 is prostate cancer cell line, A375 is malignant melanoma cell line, Bcap-37 is breast cancer cell line, and A431 is epidermoid carcinoma cell line. The entire cancer cell lines were maintained in the RPMI 1640 medium. They were supplemented with 10% heat-inactivated fetal bovine serum (FBS) in a humidified atmosphere of 5% CO3/well) were plated in 100 μL of medium/well in 96-well plate. After incubations overnight, the cells were treated with different concentrations of extracts in RPMI 1640 with 10% FBS for 72 h. In parallel, the cells treated with 0.1% DMSO served as negative control and ADM (Adriamycin) as positive control. Finally, 100 μL of MTT was added, and the cells were incubated for 4 h. The MTT-formazan formed by metabolically viable cells was dissolved in 100 μL of SDS for 12 h. The absorbance was then measured at 595 nm with a microplate reader, which is directly proportional to the number of living cells in culture.All tested compounds were dissolved in DMSO and subsequently diluted in the culture medium before treatment of the cultured cells. When the cells were 80-90% confluent, they were harvested by treatment with a solution containing 0.25% trypsin, thoroughly washed and resuspended in supplemented growth medium. Cells . The fluorescence was read using fluorescence microscope.When the cells were 80-90% confluent, they were harvested by treatment with a solution containing 0.25% trypsin, thoroughly washed and resuspended in supplemented growth medium. The cells were seeded at a concentration of 5 × 104 cell/mL in a volume of 0.8 mL on a sterile cover slip in 6-well tissue culture plates, and were treated with compounds for a certain range of treatment time. The culture medium containing compounds was removed, and the cells were fixed in 4% paraformaldehyde for 10 min. The cells were washed twice with PBS, and were consequently stained with 0.5 mL of Hoechst 33258 staining for 5 min. The stained nuclei were washed twice with PBS, and were consequently observed under fluorescence microscope at 350 nm excitation and 460 nm emissions.When the cells were 80-90% confluent, they were harvested by treatment with a solution containing 0.25% trypsin, thoroughly washed and resuspended in supplemented growth medium. The cells were seeded at a concentration of 5 × 104 cell/mL in a volume of 0.8 mL on a sterile cover slip in 6-well tissue culture plates, and were treated with compounds for a certain range of treatment time. A) The MGC-803 and PC3 cells grown in 6-well tissue culture plates were washed with PBS and fixed in 4% paraformaldehyde for 40 min. B) The cells were washed once with PBS, and were then permeabilized with immunol staining wash buffer for 2 min on ice. The cells were rewashed once with PBS, and subsequently incubated in 0.3% H2O2 in methanol at room temperature for 20 min to inactivate the endogenous peroxidases, after which the cells were washed thrice with PBS. C) Thereafter, the cells were incubated with 2 μL of TdT-enzyme and 48 μL of Biotin-dUTP per specimen for 60 min at 37°C. The cells were terminated for 10 min, and were subsequently incubated with streptavidin-HRP (50 μL per specimen) conjugate diluted at 1:50 in sample diluent for 30 min. D) The cells were washed three times with PBS, and were then incubated with diaminobenzidine solution (200 μL per specimen) for 10 min. E) The cells were rewashed twice with PBS, and were finally imaged under biological microscope.When the cells were 80-90% confluent, they were harvested by treatment with a solution containing 0.25% trypsin, thoroughly washed and resuspended in supplemented growth medium. The cells were seeded at a concentration of 5 × 106/mL) were washed twice with cold PBS and then re-suspended gently in 500 μL binding buffer. Then the cells were stained in 5 μL Annexin V-FITC and shaked well. 5 μL PI was added to these cells and incubated for 20 min in a dark place, analyzed by FACS.Prepared MGC-803 and PC3 cells (1×10All statistical analyses were performed using SPSS 10.0, and the data were analyzed using one-way ANOVA. The mean separations were performed using the least significant difference method. Each experiment was performed in triplicate, and all experiments were run thrice and yielded similar results. Measurements from all the replicates were combined, and the treatment effects were analyzed.We have no competing interesting.SY synthesized the compounds and carried out most of the bioassay experiments. NL and HL did part of the bioassay experiments. WX took part in the compound structural elucidation and bioassay experiments. DH and LJ carried out some structure elucidation experiments. QZ assisted in structural elucidation experiments. Prof. SY is the co-corresponding author for this work. All authors read and approved the final manuscript.Experimental details and data of BA derivatives. Which includes the experimental procedure, spectroscopic data, and copies of 1H NMR and 13C NMR of selected compounds.Click here for file


Shigella species, is a major public health problem in Bangladesh. To determine the prevalence and distribution of different Shigella species, we analyzed 10,827 Shigella isolates from patients between 2001 and 2011. S. flexneri was the predominant species isolated throughout the period. However, the prevalence of S. flexneri decreased from 65.7% in 2001 to 47% in 2011, whereas the prevalence of S. sonnei increased from 7.2% in 2001 to 25% in 2011. S. boydii and S. dysenteriae accounted for 17.3% and 7.7% of the isolates respectively throughout the period. Of 200 randomly selected S. sonnei isolates for extensive characterization, biotype g strains were predominant (95%) followed by biotype a (5%). Resistance to commonly used antibiotics including trimethoprim-sulfamethoxazole, nalidixic acid, ciprofloxacin, mecillinam and ampicillin was 89.5%, 86.5%, 17%, 10.5%, and 9.5%, respectively. All isolates were susceptible to ceftriaxone, cefotaxime, ceftazidime and imipenem. Ninety-eight percent of the strains had integrons belonging to class 1, 2 or both. The class 1 integron contained only dfrA5 gene, whereas among class 2 integron, 16% contained dhfrAI-sat1-aadA1-orfX gene cassettes and 84% harbored dhfrA1-sat2 gene cassettes. Plasmids of ∼5, ∼1.8 and ∼1.4 MDa in size were found in 92% of the strains, whereas only 33% of the strains carried the 120 MDa plasmid. PFGE analysis showed that strains having different integron patterns belonged to different clusters. These results show a changing trend in the prevalence of Shigella species with the emergence of multidrug resistant S. sonnei. Although S. flexneri continues to be the predominant species albeit with reduced prevalence, S. sonnei has emerged as the second most prevalent species replacing the earlier dominance by S. boydii and S. dysenteriae in Bangladesh.Shigellosis, caused by  Shigella: S. dysenteriae, S. flexneri, S. boydii, and S. sonnei and outbreaks caused by Shigella infection are difficult to control due to their low infectious dose Shigella infection and 1.1 million Shigella-related deaths. The majority of these cases occur in developing countries S. sonnei is the predominant Shigella spp. in developed as well as industrialized countries and is often the second most prevalent Shigella spp. in low income countries S. flexneri was the predominant serogroup (55%) followed by S. dysenteriae (19%), S. boydii (13%) and S. sonnei (7%) Bacillary dysentery such as shigellosis is endemic throughout the world, and is one of the major causes of morbidity and mortality, especially among children <5 years of age in many developing countries including Bangladesh Shigella is transmitted efficiently in low-dose via fecal-oral route in areas of poor hygienic conditions with limited access to clean and potable water Shigella bacteria Shigella spp. Shigella strains. Following on a recent trend of increased prevalence of S. sonnei in Bangladesh , this study was designed to determine the distribution of Shigella species and characterize randomly selected S. sonnei isolated between 2001 and 2011 in Bangladesh.In developing countries, increased resistance to commonly used antibiotics including ampicillin, streptomycin, sulfamethoxazole-trimethoprim, nalidixic acid and tetracycline has been a major concern in the treatment of enteric infections due to various bacterial pathogens Shigella strains were isolated and identified according to standard microbiological and biochemical methods Shigella spp., by serotyping with commercial Shigella antisera  S. sonnei isolates comprising at least one isolate per month and 20 isolates from each year  were randomly selected for further characterization. The strains were grown in trypticase soy broth containing 0.3% yeast extract and stored at −70°C after addition of 15% glycerol.A total of 10,827 Biotyping was done using standard methods for fermentation of rhamnose and xylose and hydrolysis of ortho-nitrophenyl-β-D-galactopyranoside (ONPG), and biotypes were designated according to methods described elsewhere E. coli ATCC 25922 and Staphylococcus aureus ATCC 25923 were used as control strains for the susceptibility tests.Antimicrobial susceptibility test was performed by the Kirby-Bauer disc diffusion method on Muller-Hinton agar plates according to the guidelines of the Clinical and Laboratory Standards Institute set1 gene (ShET-1), sen gene (ShET-2), ial gene, ipaH gene, stx genes, integrase genes , class 1 and class 2 cassette regions were performed by polymerase chain reaction (PCR) according to the procedures described previously Escherichia coli (ATCC 25922) strain lacking the140 MDa invasive plasmid and showing susceptibility to all antibiotics was used as a negative control in the PCR assays.Detection of The nucleotide sequences of the gene cassettes in class 1 integron and class 2 integron reported in this paper were submitted to the GenBank using the National Centre for Biotechnology Information  under the accession numbers KC964096, KC993867 and KF134652, respectively.E. coli PDK-9, R1, RP4, Sa and V517 in agarose gels Plasmid DNA was prepared according to the alkaline lysis method of Kado and Liu (1981) with some modifications Salmonella Braenderup H9812 strain as molecular weight standard for normalization as recommended previously XbaI and fragments were separated using a CHEF DR II apparatus (Bio-Rad Laboratories) under the following conditions: switching time from 2.2 to 54.2 s at 6 V cm−1 for 20 h at 14°C. The resulting profiles were analysed as described earlier PFGE was performed following the PulseNet protocol using the Shigella species isolated from patients of all ages between 2001 and 2011, S. flexneri was the dominant species throughout the study period, but the decreasing tendency of predominance was observed starting from 65.7% (824/1252) in 2001 to 47% (306/650) in 2011. At the same time, the prevalence of S. dysenteriae came down from 10.7% (135/1252) in 2001 to 9% (60/650) in 2011, whereas S. sonnei increased from 7.2% (90/1252) in 2001 to 25% (162/650) in 2011. The frequency of S. boydii increased from 14.6% (185/1252) in 2001 to 16.1% (104/650) in 2011 among all age groups of patients in urban areas of Bangladesh (Shigella but could not be identified to the species level and were therefore designated as Shigella-like organisms (SLOs) which accounted for about 3% of isolates. None of the SLOs agglutinated with any antisera of the established Shigella serovars.Of 10,827 strains of ngladesh . There wS. sonnei, 95% (n = 190) were classified as biotype g  and 5% (n = 10) were belonged to biotype a .Of 200 strains of R (100%), StrRSxtR (89.5%), StrRNaR (89.5%), StrRTeR (84.5%), StrRSxtRTeR (83.5%), StrRSxtRNaR (79%), StrRSxtRNaRTeR (74%) and StrRSxtRNaRCipR TeR (12%)  was detected in 94% (188) of the strains. All the strains were resistant to streptomycin and were susceptible to imipenem, ceftriaxone, cefotaxime, and ceftazidime. Resistance to commonly used antibiotics such as trimethoprim-sulfamethoxazole, nalidixic acid, tetracycline, ciprofloxacin, mecillinam and ampicillin was 89.5%, 86.5%, 84.5%, 17%, 10.5%, and 9.5% respectively. The most prevalent antimicrobial resistance patterns were StreR (12%) .ipaH gene was detected in all tested strains but none of the strains contained stx1 and set1 genes, while only 30% (60/200) strains carried both the ial and sen gene. Of all the strains, 97.5% (195) harbored integrons belonging to either class 1 or 2, or both. Of these strains, two strains carried only class 1 integron (int1), whereas only class 2 integron (int2) was identified in 95% (190) of the strains. None of the strains harbored class 3 integron. Both int1 and int2 integrons were present in three strains (1.5%). Only five strains (2.5%) were lacking both classes of integrons.The dfrA5) by DNA sequencing (GenBank accession number KC964096). Two different types of gene cassette arrays were detected using the primer pair hep74-hep51, specific for the gene cassettes of int2. The type-1 1325 bp DNA product of PCR was present in 84% (162/195) of the strains as sequence dhfrA1-sat2 and 16% (31/195) had 2159 bp band as sequence dhfrAI-sat1-aadA1-orfX with the GenBank accession number KC993867 and KF134652, respectively.Using the hep58-hep59 primer pairs, specific for the gene cassettes of int1, one type of gene cassette array (562 bp size) was found in five strains and confirmed as dihydrofolate reductase gene type 5  of the strains and were considered to be the core plasmids of . sonnei . Interes. sonnei .XbaI-digested chromosomal DNA of S. sonnei strains yielded 15–24 reproducible DNA fragments, ranging in size from approximately ∼20 to 485 kb. These strains yielded four major clusters designated: pulsotype A (n = 88), B (n = 17), C (n = 2) and D (n = 3). The similarity indexes for each cluster were 97.5%, 98.9%, 81.7% and 88.3% respectively. The major pulsotype A was further subdivided into three subtypes (A1–A3) and pulsotype B into two subtypes (B1–B2)  .All strains belonging to pulsotype A harbored ∼1325 bp int2 and pulsotype B carried ∼2159 bp int2. Strains lacking integrons were grouped into pulsotype C. Pulsotype D contained two strains which harbored both integrons and one strain which harbored only int1. All strains of pulsotypes A and B were biotype g, whereas the rest were biotype a .Shigella species, with special emphasis on characterization of the recent endemic S. sonnei in Bangladesh. A changing trend in the distribution of Shigella species was found in this study. The rising trend of shigellosis due to S. sonnei (7.2% to 25%) and S. boydii (14.8% in 23to 16.1%), and decreasing trend due to S. flexneri (65.8% to 47%) and S. dysenteriae (10.8% to 9.2%) was observed in urban areas of Bangladesh from 2001 to 2011. In the past, from 1999 to 2003 about 8% of shigellosis cases per year was caused by S. sonneiS. sonnei from 35% (50/144) in 2010 to 41% (63/154) in 2012 was also observed in another study conducted in rural areas of Bangladesh . Similar trend was noticed in many developed and industrialized countries Plesiomonas shigelloidesThis study was done for a baseline assessment of the epidemiological features of In the present study, we found that biotype g (rhamnose non-farmenter) was the predominant (95%) biotype followed by biotype a (rhamnose farmenter). It is interesting to note that all strains were found to be rhamnose farmenter in an earlier study S. sonnei to Cip was about 10% in 2007 and increased dramatically by sevenfold (70%) in 2011. In Bangladesh, resistance of S. dysenteriae 1 to Cip was first detected as early as in 2003 but in case of S. flexneri and S. boydii it was detected in 2007 and 2008, respectively rd generation cephalosporins  and Ipm probably due to their very infrequent use as alternative therapeutic regimens in this geographic area. Notably, Ipm resistance was found in other enteric pathogens except Shigella spp. Antimicrobial resistance has emerged as a serious global public health concern. In low and middle income countries including Bangladesh, the declining susceptibility to commonly used antibiotics and emergence of MDR bacteria have been linked to the indiscriminate or inappropriate use of antibiotics. The other contributing factors include bacterial evolution, climate changes, cheap and ready availability of antibiotics, lack of medical practitioner with proper training, poor-quality of available drugs and unhygienic sanitary conditions S. sonnei strains possessed multiple numbers of plasmids with a heterogeneous combination but three plasmids of ∼5, ∼1.8 and ∼1.4 MDa (core plasmids) were commonly present (90%) in most S. sonneisen and ial gene and the typical 120-MDa invasive plasmid. The possible explanations for the absence of the 120 MDa plasmid might be a loss of the plasmid due to (i) long-term storage at −70°C and (ii) repeated subculturing of the strains Shigella spp. are associated with antibiotic resistance Shigella strains harbored one or two classes of integrons. The presence of integrons in Shigella species varied in numbers in diverse geographical regions Plasmid profile analysis is a well documented and important tool for epidemiological studies of enteric pathogens dfrA5 gene in int1 cassette conferred trimethoprim resistance, an observation rarely reported in S. sonneiS. flexneri and other members of EnterobacteriaceaedhfrI, sat1 and aadA. However, due to the presence of a defective integrase, some different structures have been very infrequently found in endemic S. sonnei strains dhfrI, sat1 and aadA gene compared to previous studies. Strains harboring ∼2159 bp integron showed uniform resistance to Str, Sxt and Te, whereas no specific association with antibiotic resistance pattern was found in strains containing ∼1325 bp class 2 integron. The same array of gene cassettes of int2 was found in other members of EnterobacteriaceaeS. sonnei strains from different geographical locations might be due to the independent acquisitions of the integron over time and further diversification by clonal expansion and subsequent global spreading The low prevalence (2.5%) of int1 found in this study was also detected in other countries S. sonneiShigella species S. sonnei biotype a strains were genetically more diverse than biotype g strains, and revealed that strains having different integron patterns belonged to different clusters. This finding is congruent with a previous study To date, a number of different genotyping methods including ribotyping, inter-IS1 spacer typing (IST) method, enterobacterial repetitive intergenic consensus sequence based PCR, multilocus variable-number tandem-repeat analysis (MLVA) and PFGE have been used for the epidemiological investigation and phylogenetic study of S. flexneri and at the same time a drastic increase in S. sonnei to become the second predominant species by replacing S. boydii and S. dysenteriae in Bangladesh. S. sonnei biotype g carrying int2 was prevalent. The high prevalence of integrons in Shigella may have clinical significance, as multiple gene cassettes could be integrated into integrons leading to multidrug resistance, even to broad-spectrum antibiotics such as cephalosporins and quinolones among Shigella species. Development of a suitable vaccine against S. sonnei should be a priority in order to reduce the disease burden due to Shigella infection in Bangladesh, as all S. sonnei share a common O antigen that has proven to be a potential vaccine candidate.Overall, our findings suggest a decrease in prevalence of


Radiographic lateral spine view remains the gold-standard evaluation for sagittal curvatures of the spine. Specific positioning of the forward upper extremities during radiographic exposure is recommended to ensure no vertebra is obscured. However, the postural impact of arm positions has never been verified for the normal adolescent population. As a result, no data are available about the influence of arms positioning on the sagittal positioning of the trunk.The aim of this study is to measure the effect of arm positioning on surface topography measures.In a cross-sectional study, 694 subjects  aged 10-18 years of age were examined and were scanned with a 3-dimensional (3D) telediagnostic system for postural screening. For this study, we used 3D surface topography (“3D Orthoscreen”) enhanced by structured light and accurate calibration in XYZ Cartesian space, which enables the system to measure vertical trunk inclination angle against the plumb line. The statistical analysis was performed using SAS v.9.3.No systematic difference was found between measurements in two different positions. British Standardization Institute Index (BSII) (2*SD) was 11.4°. Results for 94.2% of the subjects fulfilled the criteria for BSII. Reliability index (ICC) was 0.60; p<0.0001; higher for girls (0.65) than for boys (0.5). We discovered systematic differences between lordosis angle values in standing positions with hands hanging freely and “fingers on the clavicles”. The average value of standing position with flexed elbows was higher. Observed differences were significant regardless of gender. The correlation between results in two positions was 0.86 in girls and 0.8 in boys. No systematic differences were found for trunk vertical inclination in sagittal plane in relation to two different positions. BSII was (2*SD) 4.84. Results for 94.2% of the subjects fulfilled the criteria for BSII. The reliability intraclass correlation coefficients index represented a significant correlation between results 0.74; p<0.0001, slightly higher for girls (0.78) than for boys (0.72).We conclude that the habitual position, regardless of elbow extension or flexion, has no influence on sagittal thoracic curvature, and on vertical trunk inclination against plumb line. However, the position with fingers on the clavicles significantly influences lumbar lordosis. The 3D surface topography may help when considering the real habitual standing angles.


To report the anatomical and functional outcomes of surgery for retinal detachment associated with chorioretinal colobomas.In this retrospective interventional case series, 28 eyes of 28 patients  who had undergone surgery for retinal detachment associated with chorioretinal colobomas were evaluated regarding the type of intervention, final visual acuity and anatomical outcomes, as well as complications. Cases with less than 3 months of follow-up were excluded.Primary surgery included vitrectomy in 25 (89.3%) and scleral buckling in 3 (10.7%) eyes. The internal tamponade used in eyes undergoing vitrectomy was silicone oil in 23 (92%) eyes and 20% sulfur hexafluoride (SF6) in 2 (8%) eyes. Silicone oil was removed in 11 eyes (45.8%). The mean number of operations per eye was 1.57±0.74, mean follow-up was 40±36 months, and the retina remained attached in 26 eyes (92.9%) at final follow-up. Mean preoperative visual acuity was 2.33±0.55  logMAR which significantly improved to 1.72±0.9  logMAR postoperatively (P < 0.001), however, final median visual acuity was counting fingers at 2 m. The most common complications were cataracts (100%) and ocular hypertension (46.4%).The most prevalent surgical procedure for treatment of retinal detachment associated with chorioretinal coloboma was pars plana vitrectomy and the most frequently used tamponade was silicone oil. Although anatomical success was satisfactory, functional outcomes were not encouraging which reflects the complexity of the condition and associated abnormalities. Coloboma is a congenital defect of the eye caused by improper closure of the embryonal fissure. This condition occurs in 0.14% of the general ophthalmic population.4Outcomes of surgery for RD accompanying a chorioretinal coloboma are not as satisfying as that in the general population. Anatomical success rates of surgery in such eyes range from 40%1In this study, we report the method of operation, as well as anatomical and functional outcomes in eyes undergoing surgery for colobomatous RD.This retrospective study was based on existing data of patients with RD accompanying a chorioretinal coloboma who underwent surgery at two tertiary ophthalmic referral centers in Tehran, Labbafinejad Medical Center and Imam Hossein Medical Center, over a period of 10 years from 1997. The study was approved of by the Review Board/Ethics Committee of the Ophthalmic Research Center. Any patient with less than 3 months of follow-up was excluded.Patient demographics, pre- and postoperative examinations, and the type of surgery, as well as postoperative complications were recorded in the data sheet. Snellen visual acuity (VA) was recorded and converted to logarithm of minimum angle of resolution (logMAR) for statistical analysis. Ophthalmic examinations included slitlamp and indirect ophthalmoscopic examinations. Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. Anatomical success was defined as stable retinal reattachment posterior to the band or buckle.Statistical analysis was performed using SPSS software . Qualitative variables were described using percentages; quantitative data were defined using means and standard deviations. The paired t-test was used for comparing pre- and postoperative values. In order to compare median VA in patients with different degrees of colobomatous involvement, the Kruskal-Wallis test was used. Level of statistical significance was set at 0.05.Data from 28 eyes of 28 patients who had undergone surgery for RD accompanying chorioretinal colobomas were evaluated. Involvement of the right and left eyes was equal. Mean patient age was 32.6±14.2  years and mean duration of symptoms prior to referral was 44.8±53.3  days. Patient demographics as well as baseline clinical characteristics are shown in Three patients had history of cataract surgery and intraocular lens implantation, of whom two underwent intraocular lens removal during vitrectomy. Two other patients had history of scleral buckling (SB).Initial VA ranged between light perception and counting fingers at 3.5 m. The mean number of involved quadrants (extent of RD) was 2.96±0.79. All eyes without macular involvement by the coloboma had a detached macula at presentation. Retinal breaks were detected in 10 eyes (35.7%) preoperatively; 3 of these eyes underwent SB and 7 others  underwent vitrectomy. Preoperatively, proliferative vitreoretinopathy (PVR) grade C was present in 12 (40.8%) eyes. Ten eyes had posterior PVR only, involving 12, 9, 6, and 4 clock hours, respectively, in 1, 2, 4, and 3 eyes. The other two eyes had only anterior PVR in 6 and 3 clock hours.Three patients (10.7%) underwent primary SB surgery . One of these three patients experienced retinal re-detachment secondary to PVR and underwent lensectomy plus vitrectomy with C3F8, followed by repeat vitrectomy with silicone oil (SO) tamponade.Twenty-five eyes (89.3%) underwent vitrectomy, of which, two had previously undergone SB surgery at other centers. Vitrectomies were performed in a standard fashion employing a three-port 20-gauge pars plana approach. Encircling band (No. 240) placement and pars plana lensectomy  were performed in association with vitrectomy in 92% (23 eyes) and 90.9% (20 of 22 of phakic eyes), respectively. Intraocular lens removal was performed in two eyes. All eyes underwent intraoperative laser therapy around the colobomatous area and retinal breaks followed by air/fluid exchange. In three eyes, retinal breaks were detected during the operation. Intraocular tamponade included 20% sulphur hexafluoride (SF6) in 2 (8%) eyes and SO in 23 eyes (92%).Retinal reattachment was achieved in all eyes at the end of the procedures and in the early post-operative period. Overall, the mean number of procedures  was 1.57±0.74 for each eye; 16 eyes (57.1%) underwent surgery once, 7 eyes (25.1%) were operated twice, and 5 eyes (17.8%) required surgery three times.SO removal was performed in 11 of 24 eyes (45.8%). The reasons for retaining SO (13 eyes) were surgeons’ preference (11 eyes) and patients’ non-compliance for removal (2 eyes). SO removal resulted in retinal re-detachment in 3 eyes. All 3 eyes underwent repeat vitrectomy with SO tamponade which was anatomically successful. Retinal re-detachment occurred in two eyes with SO in place. Re-operation was not scheduled for them due to poor visual prognosis.Mean preoperative VA was 2.33±0.55  logMAR which significantly improved to 1.72±0.9  logMAR postoperatively (P<0.001). Maximum and minimum preoperative VA was counting fingers at 3.5 m and light perception, respectively; these improved to 20/60 and no light perception after intervention. The change in median VA from hand motions to counting fingers at 2 m after the operations was also significant (P=0.001).The distribution of Snellen visual acuity based on the site and extent of the coloboma is presented in Eventually and with a mean follow-up duration of 40±36  months, the retina remained attached in 26 eyes (92.9%) and detached in 2 eyes (7.1%). The retina remained attached in the two eyes for which SF6 was used for internal tamponade.Two patients undergoing SB were phakic and the crystalline lens was preserved in two patients in the vitrectomy group. Cataract progression was observed in all 4 eyes necessitating cataract surgery in 2 eyes. The encircling band was removed in one eye because of band extrusion.Of 3 eyes initially undergoing SB, IOP rise occurred in the only eye requiring vitrectomy plus C3F8 injection. In the vitrectomy group, 12 eyes (48%) developed high IOP necessitating the use of glaucoma medications. The tamponade used in these eyes was SF6 in 2 and SO in 10 eyes. Of the latter 10 eyes, five had retained SO but the other five had undergone SO removal 4 to 20 months after the procedure, when IOP rise occurred. IOP was controlled with medications in 8 eyes including the two eyes with SF6. However, the glaucoma was refractory to medical therapy in 4 eyes including 2 eyes with removed SO and 2 with retained SO. Of these 4 eyes, 2 with 20/120 and counting fingers at 3m vision underwent glaucoma surgery. The other 2 eyes were not expected to regain useful vision (one with light perception vision and one with recurrent RD) and were thus only observed.Mean follow-up in this study 40 months) was longer than that of some other large studies 13.4 months r0 months The present study demonstrated that despite a good anatomical success rate and significant visual improvement, final visual acuity was not satisfactory. Visual acuity equal to or better than 20/400 was achieved in only 35.7% of operated eyes in the current series, however, this level of vision was reported in 69.9%Although SB can be considered as a treatment modality in eyes with colobomatous RD,The preferred surgical procedure in our study was vitrectomy in 89.3% of eyes. The possibility of finding breaks is higher with vitrectomy. Vitrectomy with SO tamponade was successfully employed for colobomatous RD for the first time in 1983.Lensectomy was performed in 90.9% of phakic eyes in our study. Lensectomy in addition to vitrectomy was performed in 71.4%Silicone oil has been preferred for tamponade in colobomatous RD repair by most surgeons.Silicone oil removal was performed in nearly half of our patients which is comparable to other studies.7Most eyes underwent lensectomy during vitrectomy. Cataract progression occurred in all eyes which had remained phakic after the operation (vitrectomy or SB). Increased IOP was another common complication in our patients which occurred in 46.4% of vitrectomized eyes and was controlled with medications in most cases. In 14% (4 out of 13 cases), the glaucoma was refractory to medical therapy. The rate of IOP rise in the current study was more than other reports 16.3%. This di5The shortcoming of this study is its retrospective nature. In addition, we were unable to compare vitrectomy with SB, and SO versus gas in the management of colobomatous RD.This retrospective study adds more data to the literature regarding the preferred surgical options, as well as visual and anatomical outcomes of RD repair in eyes with chorioretinal coloboma. Based on this report and similar studies, vitrectomy with SO tamponade may be a good choice for management of colobomatous RD. Despite an acceptable anatomical result, the functional outcome is rather poor which reflects involvement of vital structures in the eye as well as amblyopia. Ocular hypertension is a complication that deserves careful pre- and postoperative evaluation.


Dermatologic disorders are common in many countries but the spectrum varies greatly. Many studies have reported a significant burden of skin diseases in school children. The objective of this study was to determine the current spectrum of dermatological disorders in primary school children in Dar es Salaam city.Primary school children were recruited by multistage sampling. Detailed interview, dermatological examination and appropriate laboratory investigations were performed. Data was analyzed using the 'Statistical Package for Social Sciences' (SPSS) program version 10.0 and EPI6. A p-value of < 0.5 was significant.Microsporum canis was common in tinea capitis  followed by Trichophyton violaceum . Trichophyton rubrum was common in tinea pedis . Thirty six children (8.6%) had pityriasis versicolor which was more prevalent  in the age group 16-19 years (p = 0.0004). The other common infectious dermatoses were pyodermas (4%) and pediculosis capitis (3.6%). Common non-infectious dermatoses were: acne vulgaris (36.4%), non-specific dermatoses (10.7%), non-specific ulcers (5%) and atopic eczema (2.6%). Rare conditions  included: vitiligo, alopecia areata and intertrigo. The majority of the affected children (67.2%) did not seek any medical assistance.A total of 420 children were recruited . The overall point prevalence of any skin disorder was 57.3% and it was 61.9% and 52.6% in males and females respectively (p = 0.05). Infectious dermatoses accounted for 30.4% with superficial fungal infections (dermatophytoses and pityriasis versicolor) being the commonest (20%). Dermatophytoses were diagnosed in 11.4% (48/420); the prevalence in males and females being 12.6% and 10.1% respectively (p = 0.41) and higher (21.8%) in the age-group 6-10 years (p = 0.045). Fungal cultures were positive in 42/48 children (88%). All three dermatophyte genera were isolated. Tinea capitis was the commonest disease among culture-positive dermatophytoses  with an overall prevalence of 7.1% (30/420) followed by tinea pedis  whose overall prevalence was 2.6%. Skin disorders are common in primary school children; infectious dermatoses are still rampant and many children do not seek medical assistance. Studies from developing countries conducted over a period of years in the past have reported high prevalence of skin disorders among school children, the spectrum of which has been highly variable. In a review of prevalence studies in children by WHO, the prevalence of skin diseases ranging from 21% to 87% has been documented .Elsewhere in the world, similar prevalence figures have been reported. In Turkey, Isil Inanir et al reported a prevalence of skin disorders of 77% among primary school children. Infectious dermatoses were frequently observed; pediculosis capitis, scabies, viral diseases and fungal infections .A study done in rural Tanzania reported 55% of the school children as having one or more skin diseases ,7. A morThis was a descriptive cross-sectional study conducted in public primary schools of Dar es Salaam city.A multi stage sampling technique was employed. Primary schools were selected from all municipals of Dar es Salaam city using random number tables. A sampling fraction of 4.6% was used in each school to get the required number of children who were then recruited by a simple random technique. School children were recruited regardless of the strict age-definition of the term 'child,' provided they were still in primary schools.Recruited children were interviewed and examined in day light. Dermatological diagnosis was made mainly clinically. Laboratory investigations were used to confirm difficult diagnoses. Skin scrapings, nail clippings and hairs were obtained as appropriate and treated for 15-30 minutes with 1-2 drops of 20% KOH before being examined microscopically for fungal hyphae. Fungal cultures were done on Sabouraud's Dextrose Agar and considered positive if there was growth on day 14 or 28 and negative if there was no growth on day 28. Pus swabs were collected for gram stain and cultures were done on Blood and MacConkey Agar. The bacterial cultures were considered negative if there was no growth after 48 hours of incubation. Specimens were obtained from burrows of suspected scabies lesions for direct microcopy for mites. Skin biopsies were taken as appropriate for routine histological examination. There were no special tests done to confirm viral lesions.Data was entered into a computer and counterchecked to ensure correctness of entries. Analysis was done using the Statistical Package for Social Sciences (SPSS) version 10.0. Chi-squared and Fisher's exact statistical tests were used to determine associations for categorical variables. A p-value of less than 0.05 was considered statistically significant.Ethical clearance was obtained from the 'Muhimbili University of Health and Allied Sciences' Ethics Board. Confidentiality on candidate's information was maintained.A total of 420 primary school children were recruited. Of these, 213 (51%) were males. The age ranged from 6 to 19 years, (mean 11.4 ± 2.8 years). Twenty seven pupils (6.4%) were much older, aged above 15 years. The mean family size was 6.3 ± 2.4 and the mean number of persons per room was 2.4 ± 1.1. The overall point prevalence of any skin disease was 57.3% (241/420) with 48% having one, 9% two and 1% three. The prevalence of any skin disorder was 61.9% (132/213) in males and 52.6% (109/207) in females (p = 0.05).Table Trichophyton , Microsporum  and Epidermophyton . The most prevalent culture-positive dermatophytosis was tinea capitis observed in 71.4% (30/42); giving an overall prevalence of 7.1% (30/420) and M. canis was the commonest species isolated in 46.7% (14/30), followed by T. violaceum (20%). T. pedis was encountered in 26.1% (11/42), giving an overall prevalence of 2.6% (11/420) and T. rubrum was the leading etiology present in 45.4% (5/11) followed by T. mentagropyhtes in 36.4% (4/11). E. floccosum and T. schoenleinii were also isolated from children with tinea pedis; each in one child (9.1%). Only one of 42 culture-positive children (2.3%) had tinea corporis due to M. canis, giving an overall prevalence of 0.2% (1/420).Fungal cultures were performed for all 48 children and were positive in 42/48 (88%). These results have been presented separately in table Staphylococcus aureus (3), Klebsiella pneumonia (2) and Escherichia coli (1).Apart from dermatophytoses, the other superficial fungal infection encountered was pityriasis versicolor in 36 children (8.6%), which was more prevalent  in the older age group; 16-19 years (p = 0.0004). Other relatively common infective dermatoses included pyodermas (4%) and pediculosis capitis (3.6%). Scabies and viral warts were less frequent . Of the pyodermas, 13 (3.0%) were folliculitis while one child had carbuncle and only 6 specimens grew bacteria: There was a wide range of non-infective skin disorders. Many of these conditions, however, were of very low prevalence. Overall, acne vulgaris was the commonest, being encountered in 36.4% and more prevalent in children of age-group 11-15 years, . Twenty one children (5%) had mild, superficial non-specific ulcers. Atopic eczema and birthmarks had prevalence of 2.6% and 2.3% respectively. Seborrheic eczema, keratosis pilaris and angular cheilitis were less frequent, each with prevalence of 1.2%. Conditions with very low prevalence (< 1%) were vitiligo, alopecia areata, and intertrigo. Non-specific dermatoses occurred in 10.7% (45/420), being common  in older children aged 16-19 years (p = 0.0001).The majority of the children (67.2%) did not seek any medical care for their skin diseases. Few (16.6%), visited hospitals while others (14.5%) practiced self medication and a minority went to traditional healers (1.2%) or used Chinese medicine (0.4%).This study has documented the current spectrum of skin diseases among school children in an urban setting of a developing sub Saharan African country. The point prevalence of any skin disorder of 57% is alarmingly high and still comparable to that of a previous study (55%) among school children in rural Tanzania ,3. The tMicrosporum canis was the commonest isolate (35.7%), followed by Trichophyton mentagrophytes (19%) and Trichophyton rubrum (19%). In an Iranian study conducted one and a half decades ago, Khosravi AR et al, also found the highest frequency with Microsporum canis (19%) followed by Trichophyton rubrum (16.5% and Epidermophyton floccosum (15%) [T. rubrum, while another one had tinea pedis caused by E. floccosum, and yet another one had tinea pedis due to T. schoenleinii. All these are rare findings. Although the numbers involved are very small, these findings call for more comprehensive studies to define clearly the prevalence of these organisms and their role in causing different fungal diseases in African primary school children. Our study also found tinea pedis to be more prevalent (2.6%) than tinea corporis (0.2%) which is not usual in children. This could be due to the fact that our study was conducted in Dar es Salaam, a city with a hot, humid climate almost throughout the year, with school children having adopted the western style of life, of wearing closed shoes at all times while at school and most of the times at homes all of which would make them at risk of developing tinea pedis. Tinea corporis on the other hand is usually more common in rural areas.Many studies have reported infectious dermatoses as comprising more than one-third of all skin disorders ,3,5,7,9.um (15%) . Elsewheum (15%) -13. In oThe older children were more likely to have pityriasis versicolor as the condition is more common in the post-pubertal age where sebaceous glands are active . The lowAtopic eczema and seborrheic eczema were observed with lower frequencies of 2.6% and 1.2% respectively. This is consistent with observations in the general population where atopic eczema and seborrheic eczema in children have been found to vary from less than 1% to 5% [The majority of the school children in this study (67%) did not seek any form of treatment for their skin conditions. The low level of medical care seeking behavior has also been demonstrated among secondary school children with acne vulgaris . This atUnlike non-infective dermatoses, many of which are genetic, autoimmune or idiopathic in etiology and therefore difficult to prevent, many infectious dermatoses are easy to treat and even prevent. It is surprising therefore to find a trend of infectious skin diseases which is still similar to that described several decades ago.Skin disorders are common among school children affecting about two thirds of them but the majority does not seek medical advice. There is need to strengthen school health programs so that regular skin examination and proper advice to affected children can be provided.This being a point prevalence cross-section study, the total skin disease burden is most likely underestimated since point prevalence studies often miss diseases of short duration.The authors declare that they had no competing interests during the design up to the conduct of this study.EVK participated in the study design and conducted data collection. YMM conceived the study theme, participated in the study design, supervised data collection and prepared the final manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/765/prepub


Clinical, biological, immunogenetic, and radiographical data were analyzed at study entry and at 24 months. Presence of radiographic progression was retained when the total score was superior to the smallest detectable difference (SDD) calculated to be 5.4 according the Sharp/van der Heijde (SVDH) method.Fifty one patients  were enrolled in this study. 68.6% were illiterate and 19.6% reported at least one comorbid condition. The mean delay in referral for specialist care was 140 [ 7-420 ] ± 43 days.Thirteen patients (62.5%) were IgM or IgA RF positive. HLA-DRB1*01 and DRB1*04 alleles were present respectively in 11.8% and 45.1% of patients.At baseline, 35.3% patients were taking corticosteroids and 7.8% were under conventional DMARDs.At 24 months, 77.2% received a median dose of 5 mg/day of prednisone. Methotrexate (MTX) was the most frequently prescribed DMARD, being taken by 65.2% of patients. 13.6% of patients had stopped their DMARD because of socioeconomic difficulties.Comparison of clinical and biologic parameters between baseline and 24 months thereafter revealed a significant global improvement of the disease status including morning stiffness, pain score, swollen joint count, DAS 28 and HAQ scores, ESR and CRP.P < 0.001.Sixteen patients (34.8%) were in remission at 2 years versus no patients at baseline; P = 0.04) and joint space narrowing score (P = 0.03). No independent factors of radiographic progression were shown by logistic regression.Forteen patients (27.5%) had at least one erosion at baseline. Radiographic progression occurred in 33.3% of patients and was associated in univariate analysis to swollen joint count (p = 0.03), total SVDH score (These study reports, provided for the first time in Morocco, a developing African country, a large amount of information concerning the profile and the course of early RA.Patients who were receiving, for most of them, Methotrexate in monotherapy and low doses of corticosteroids, showed an improvement of all clinic and biologic disease parameters. Moreover, DAS remission was obtained in one third of patients and two thirds of the cohort had no radiographic progression at 2 years. No predictor factors of radiographic progression were found out.These results should be confirmed or not by a large unbiased RA cohort which will give more relevant information about early RA characteristics and its course and will constitute a major keystone of its management. Rheumatoid arthritis (RA) is the most common inflammatory chronic disease of the joints. It is characterized by disease activity and bone destruction resulting in joint destruction, functional impairment, and increased mortality -3. In MoEarly recognition of RA and intervention appear to be keys to optimal management of this chronic disabling disease . There iA cohort of consecutive adults patients with RA aged between 18 and 70 years who suffered from the disease for less than 1 year was recruited in this study between January 2005 and December 2006. RA patients were diagnosed by rheumatologists with reference to the American College of Rheumatology (ACR) classification criteria  ± 10.8 years and 24 [6-48] ± 13.9 weeks. The mean delay in referral for specialist care was 140 [7-420] ± 43 days. Thirteen patients (62.5%) were IgM or IgA RF positive. Positivity of ACPA was noted in 56.6% of patients.HLA-DRB1*01 and DRB1*04 alleles were present respectively in 11.8% and 45.1% of patients. At baseline, DAS 28 and HAQ scores were respectively 6.9 [3.7- 9.9] ± 1.3 and 2.2 [0.7-3] ± 0.6.At study entry, eighteen patients (35.3%) were already taking corticosteroids and 4 patients (7.8%) were under conventional DMARDs (Methotrexate (n = 1) and Methotrexate associated to Chloroquine (n = 3)).At 24 months assessment, thirty four patients (77.2%) received a low dose of prednisone with a median dosage of 5 mg/day. During the study, all patients were receiving conventional DMARDs in monotherapy. Methotrexate (MTX) was the most frequently prescribed DMARD, being taken at a dose of 15 mg once a week by 65.2% of patients and followed by Sulfasalazine and Chloroquine (10.8% for each of them). At the 24 months assessment, 6 patients (13.6%) had stopped the DMARD for socioeconomic difficulties. None of patients received combination therapy or biologic agents.Table Table P < 0.001. Sixty patients (34.8%) were in remission versus no patients at baseline; P < 0.001.In RA patients, the mean DAS 28 decreased significantly from an initial mean score of 6.9 [3.7-9.9] ± 1.3 in range of high disease activity to 3.7 [0.5- 9.2] ± 1.9 into the range of moderate disease activity; P < 0.001, from 0(0-1) to 0(0-2); P < 0.001, and from 1(0-3) to 3(1-8) ); P < 0.001; (Table Forteen patients (27.5%) had at least one erosion at baseline. At 2 years, the median of total SVDH, erosions, and joint space narrowing scores increased respectively from 1(0-5) to 4(1-10);  from 10- to 3.P= 0.03), total SVDH score (P = 0.04) and joint space narrowing score (P = 0.03). No association was noted for any other variables. Logistic regression showed that there were no independent factors of radiographic progression.Table P: NS), tender joints , ESR , HAQ , DAS 28, and patient pain assessment .Comparing clinical and biologic characteristics of progressor and non-progressor patients at the 24 months, showed no significant (NS) differences in swollen joint  have stopped the DMARD due to socioeconomic difficulties. Our finding highlights once more another frequent problem in developing countries inherent to socioeconomic difficulties encountered in chronic diseases management . Rkain eThe significant improvement of the disease status including clinical and biologic parameters is in concordance with the literature findings ,22.Practically a third of patients were in remission after this period whereas there were no patients at baseline. Remission rates range from 3% to 68%  in RA stOur study has provided large information on structural progression. Forty patients (27.5%) had at least one erosion at baseline. Previous studies have widely demonstrated that joint damage in RA occurs early in the disease process . PatientTwo thirds of our patients did not show any significant radiographic progression after 2 years of follow-up.Comparison of this result with literature is difficult because of the differences in the study design, patients and disease features.Both nonprogressor and progressor patients showed significant improvement of clinical and biologic baseline parameters. Those findings are in line with previous data showing that radiological progression occurs despite a clinically and biologically acceptable disease control ,28.Traditional therapy with a single DMARD is often insufficient to prevent a poor long-term outcome of rheumatoid arthritis (RA) . Trials Many predictor factors of structural progression were reported in literature -35. AccoMany limitations should be recognized in our study. First, we recognize that choosing the ACR 1987 classification criteria for RA to recruit patients may be criticized and could be a bias recruitment, possibly misjudging the baseline structural damage. But at our study onset, a few years ago, Early arthritis was "ill-defined": in some studies a disease duration of up to three years was accepted, whereas other protocols required a much shorter maximum duration of symptoms . In addiMore than a research subject, this study gave us as clinicians the opportunity to find out the early RA profile in the Moroccan context.This study reports, for the first time in Morocco, a developing African country, a large amount of information concerning the profile and the course of early RA.Patients, receiving, for most of them, Methotrexate in monotherapy and low doses of corticosteroids, showed an improvement of all clinical and biological disease parameters. Moreover, remission was obtained in one third of patients and two thirds of the cohort had no radiographic progression at 2 years. No predictor factors of radiographic progression were found out probably in relation with the small number of patients.The findings of this study also highlight the difficulties of early RA in developing countries. The delay in referral to specialists and interruption of DMARD due to financial difficulties are the most important problems encountered in our context.The small size of our sample and the absence of regular monitoring of clinical, biological and radiographical parameters during the course of the disease are the most important limitations of our study.The best way to investigate the course of early RA in the Moroccan population would be through a prospective longitudinal study, following an unbiased cohort of patients with early RA with regular clinical, biological and radiographical assessments for many years. Such multicentric inception cohort of early arthritis with a larger sample will give more precious informations about early RA characteristics and course and will constitute a major keystone in the management of this disabling disease in our country. Such a prospective study is already ongoing in Morocco.The authors declare that they have no competing interests.KB, NHH and MD conceived the study and supervised its design and execution. FB, BB, AB and LB were involved in sample collection. HR, RA, BB and LB and did data management and statistical analyses. OA and ME carried out HLA typing. HR wrote the paper with input from all investigators. All authors were involved in drafting manuscript and revising it for critically important content. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/266/prepub


The aim of this study was to assess the prevalence of (unknown) heart failure and left ventricular dysfunction in older patients with type 2 diabetes.In total, 605 patients aged 60 years or over with type 2 diabetes in the south west of the Netherlands participated in this cross-sectional study (response rate 48.7%), including 24 with a cardiologist-confirmed diagnosis of heart failure. Between February 2009 and March 2010, the patients without known heart failure underwent a standardised diagnostic work-up, including medical history, physical examination, ECG and echocardiography. An expert panel used the criteria of the European Society of Cardiology to diagnose heart failure.Of the 581 patients studied, 161  were found to have previously unknown heart failure: 28  with reduced ejection fraction, and 133  with preserved ejection fraction. The prevalence of heart failure increased steeply with age. Heart failure with preserved ejection fraction was more common in women. Left ventricular dysfunction was diagnosed in 150 patients ; 146  had diastolic dysfunction.This is the first epidemiological study that provides exact prevalence estimates of (previously unknown) heart failure and left ventricular dysfunction in a representative sample of patients with type 2 diabetes. Previously unknown heart failure and left ventricular dysfunction are highly prevalent. Physicians should pay special attention to ‘unmasking’ these patients. Cardiovascular diseases are of major importance in patients with type 2 diabetes, accounting for up to 80% of the excess mortality in these patients . ProcessTo our knowledge, exact prevalence estimates of (unrecognised) heart failure, with and without reduced ejection fraction, and systolic and diastolic dysfunction in a representative sample of all older patients with type 2 diabetes are lacking. We therefore assessed this prevalence in patients aged 60 years and older with type 2 diabetes, all undergoing echocardiography.The study was conducted between February 2009 and March 2010, in the province of Zeeland, in the south west of the Netherlands. We were able to invite a representative group of patients with type 2 diabetes, at least for Western Europe, because all patients with type 2 diabetes in this region are enrolled in the Diabetes Care programme of the Center for Diagnostic Support in Primary Care (SHL), including those (co-)treated by hospital specialists . Of all the patients with type 2 diabetes from the participating physicians in this study, 1,243 were 60 years or older, and were invited.www.ccmo.nl, NL2271704108.All participants gave written informed consent, and the institutional review board of the University Medical Center Utrecht and the Admiraal de Ruyter Hospital in Goes, the Netherlands approved the study protocol. The protocol of the study has been published previously  and the 1c. NT-proBNP was measured with a non-competitive immunoradiometric assay .The patients without a cardiologist-confirmed diagnosis of heart failure (i.e. including echocardiographic evidence of left ventricular dysfunction) underwent a standardised diagnostic assessment, which was executed in the cardiology outpatient department of the Admiraal de Ruyter Hospital in Goes. Information on duration of diabetes, smoking habits and comorbidities was obtained from the patients and the registry. Patients were asked to bring their medication packages so that current drug treatment could be checked. The presence of angina pectoris and shortness of breath was assessed with the WHO questionnaires . SymptomEchocardiography was performed with a General Electric, Vivid 7 imaging system device  by well-trained and experienced cardiac sonographers. Variables from Doppler analysis, M-mode echocardiography and two-dimensional transthoracic echocardiography were used. Where image quality was adequate, left-ventricular ejection fraction (LVEF) was calculated from the endocardial surface tracings in the apical four-chamber view and two-chamber view, using Simpson’s rule (disc summation method) , 15.2 were used for normal and definitely increased LA volume index, respectively  mmol/mol), creatinine 81.7 (SD 15.9) μmol/l, and modification of diet in renal disease (MDRD) 82.8 (SD 15.4) ml min−1 1.73 m−2. The mean age of non-responders was 77.0 (SD 9.1) years, the percentage of men 43.4 , HbA1c 6.7% (SD 0.6%) (49.4 [SD 6.8] mmol/mol), creatinine 84.5 (SD 19.7) μmol/l and MDRD 79.0 (SD 17.9) ml min−1 1.73 m−2. Table In total, 605 patients agreed to participate (response rate 48.7%), 581 of them without a cardiologist-confirmed diagnosis of heart failure. The mean age of the 605 responders was 71.5 (SD 7.5) years, and 54.0%  were male. The mean HbAOf the 581 patients previously not known to have heart failure, 161 were diagnosed with heart failure : 28  with HFREF, 133  with HFPEF, and none with right-sided heart failure. Of those with HFREF, nine had an LVEF ≤ 40%, and 19 an LVEF between 40% and 45%. The overall prevalence of heart failure among the 605 patients was 185 : 35  with HFREF, and 150  with HFPEF. In addition, five patients were classified as having possible heart failure by the expert panel: one with HFREF, three with HFPEF, and one with right-sided heart failure. Sex-specific prevalence rates for 5-year age groups of previously unknown HFREF and HFPEF are shown in Table 2 and 23.4%  in those with a BMI <30 kg/m2. In patients with dyspnoea, the prevalence was 46.6%  and 13.3%  in those without dyspnoea. In patients with fatigue, the prevalence was 45.6%  and in those without fatigue 16.1% . In patients treated for hypertension, the prevalence was 31.2%  and in those not treated for hypertension 21% .The prevalence was 38.7%  in patients with a BMI ≥ 30 kg/mIn addition, left ventricular dysfunction was diagnosed in 150 patients ; nearly all (97.3%) had diastolic dysfunction. Of the 581 patients, 264 (45.4%) had ‘normal’ left ventricular function, although 65 (11.2%) had an LVEF 45–55% (without diastolic dysfunction) and could be considered to have suboptimal systolic left ventricular function. Prevalence rates for diastolic and systolic dysfunction are shown in Table According to the panel, hypertension with or without left ventricular hypertrophy was the most common cause (82%) of heart failure, followed by prior myocardial infarction (23%) and other ischaemic heart disease (39.8%) Table . If the 2 (38.7% vs 23.4%), in patients with dyspnoea (46.6% vs 13.3%), in patients complaining of fatigue (45.6% vs 16.1%) and treated for hypertension (31.2% vs 21%). The majority (82.6%) of the patients with newly detected heart failure had HFPEF . Moreover, the prevalence of left ventricular dysfunction (25.8%), mainly diastolic dysfunction (25.1%), was high. Only 264 (45.4%) of all investigated patients had ‘normal’ left ventricular function, including 65 (11.2%) with a suboptimal LVEF of 45–55%.Our study in a large representative group of older patients with type 2 diabetes showed that the prevalence of previously unknown heart failure is very high (27.7%), steeply increases with age, and is overall higher in women (31.0%) than men (24.8%). The prevalence is significantly higher in patients with a BMI ≥ 30 kg/mThe high prevalence of previously unknown heart failure could be due to patients with symptoms of heart failure not going to a physician or physicians not asking the patient about these symptoms. A further possibility is that when patients do present with these symptoms, physicians do not recognise heart failure.Hypertension was presumed to be the most important possible cause of heart failure in our study population, according to the panel. Previous studies have shown that hypertension generates a high population attributable risk of heart failure  and diasThe exact reason for the high prevalence of diastolic dysfunction is not known, although it may be related to early stages of so-called ‘diabetic cardiomyopathy’ . Our finSeveral limitations of our study should be discussed. The relatively high blood pressure values could be the result of the single measurement used in our study. Importantly, this had no influence on the prevalence estimates of the cause of heart failure adjudged by the panel, since the panel used a history of high blood pressure rather than current blood pressure levels. NT-proBNP levels were not available to the panel, to prevent incorporating bias for the diagnostic part of the study that will be performed. This may have had some influence on the panel’s diagnosis, although the effect is likely to be small because, in all participants, a complete echocardiographic assessment, including tissue Doppler imaging measurements, was available. When evaluating the possible causes of heart failure, it is important to consider that the panel judged ‘likely’ causes on the basis of the diagnostic assessment, but without specific and detailed further investigations. Under-rating the importance of ischaemia as the possible cause of heart failure is therefore likely.One of the strengths of the study is a relatively high response rate (48.7%) compared with other population-based studies involving extensive diagnostic testing . As can The prevalence of previously unknown heart failure in our study 27.7%) is even higher than reported in patients aged 65 years and older with chronic obstructive pulmonary disease . Several.7% is evThe prevalence of left ventricular dysfunction in our study, when we include those diagnosed with heart failure, would be 53.5%: 48.0% diastolic dysfunction and 5.5% systolic dysfunction. In addition, 11.2% had suboptimal systolic ventricular dysfunction (LVEF 45–55%). Henry et al  reportedScreening of patients with type 2 diabetes should be considered in the light of the high rates of prevalence (27.7%) of previously unknown heart failure in older patients with type 2 diabetes observed in our study. Physicians should be constantly alert for signs and symptoms indicative of heart failure in these patients. In addition, echocardiography and/or ECG or B-type natriuretic peptide measurements could be part of the yearly monitoring. We need to determine which screening strategy is the most efficient. Although evidence on how to optimally treat patients with HFPEF is scarce, there is consensus that at least optimising blood pressure and reducing heart rate in patients with tachycardia is needed, combined with optimal treatment of (cardiac) comorbidities , 39. An