Surgery for colorectal cancer conveys a high risk of venous thromboembolism (VTE). The effect of thromboprophylactic regimens of varying duration on the incidence of VTE was assessed in 417 patients undergoing surgery between 2005 and 2009 for colorectal cancer. Low-dose unfractionated heparin (LDUH) was used in 52.7% of patients, low-molecular-weight heparin (LMWH) in 35.3%, and 10.7% received LDUH followed by LMWH. Pharmacological prophylaxis was continued after hospitalisation in 31.6%. Major bleeding occurred in 4% of patients. The 30-day mortality rate was 1.9%. The incidence of symptomatic VTE from hospital admission for surgery to 12 months after was 2.4%. There were no in-hospital VTE events. The majority of events occurred in the three-month period after discharge, but there were VTE events up to 12 months, especially in patients with more advanced cancer and multiple comorbidities. Major surgery conveys a significant risk of venous thromboembolism (VTE), a condition that encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE). The first-time incidence of VTE in the general population is approximately 100 persons per 100,000 per year . There aIn the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines, colorectal cancer surgery patients are judged as having a high risk of VTE and are recommended to receive both anticoagulant and mechanical VTE prophylaxis unless contraindicated . For antIn 2009, the National Health and Medical Research Council (NHMRC) of Australia produced evidence-based clinical practice guidelines for the prevention of VTE to improve the application of VTE prophylaxis recommendations in Australian hospitals . These gThe current study was undertaken to review the effect of different types and duration of thromboprophylactic modalities on VTE incidence and to evaluate the incidence and risk factors for bleeding complications in patients undergoing surgery for colorectal cancer.From January 1, 2005 to December 31, 2009, 417 patients who underwent colorectal surgery for suspected or confirmed malignancy were identified from the Westmead Hospital Department of Surgery database registry. All patient records were analysed retrospectively for the occurrence of DVT and/or PE, 30-day mortality, and hospital readmission within three months and twelve months of surgery.From this study population, a computer-generated random sample of 150 patients, 30 per year, was selected using Statistical Product and Service Solutions version 16.0 . The medical records of these patients were then reviewed for the following variables: patient demographics, diagnosis and co-morbidities, preoperative haemoglobin level, operative and anaesthetic details, pre- and postoperative VTE prophylaxis, and postoperative complications, including major bleeding.Symptomatic DVT was confirmed by documentation of positive duplex ultrasonography for DVT and for symptomatic PE by high probability ventilation perfusion lung scan or CT pulmonary angiography. Readmission for VTE was recorded when a patient having been discharged from hospital was readmitted with VTE symptoms within a three-month period with imaging confirming a diagnosis of DVT and/or PE.Pharmacological prophylaxis was LMWH enoxaparin  administered subcutaneously (20 mg or 40 mg daily) preoperatively and/or postoperatively or LDUH subcutaneously  two or three times daily preoperatively and/or postoperatively. Pharmacological prophylaxis administration was expected to continue for seven to 10 days according to ACCP guidelines . GCS andU test. Statistical significant differences were considered at the P < .05 level and where possible 95% confidence intervals (CI) are presented.Data was entered into a specifically designed Clinical Reporting Systems database version 1.1 ma . Continuous data is given as the median and interquartile range . Continuous data groups were compared using the two-tailed Mann Whitney P < .0001). In terms of VTE risk factors, 98% (95% CI: 94.3–99.3%) of patients had confirmed malignancy with malignant neoplasm of the rectum being the most common site, accounting for 27.3% (95% CI: 20.8–34.9%) of all patients. 72.7% (95% CI: 65.0–79.2%) of patients had a cancer stage of three or higher. The median number of co-morbidities was three (IQR: 2–4.8), with 5.3% (95% CI: 2.7–10.2%) of patients having a history of VTE. 44% (95% CI: 36–52%) had an American Society of Anaesthesiology (ASA) score of three (indicating severe systemic disease) and 47% (95% CI: 39.9–55.6%) a score of two (mild systemic disease).The median patient age was 67 (IQR: 58.3–76) with a male-to-female ratio of 1 : 1. The median length of stay (LOS) was 10 days (IQR: 7–14), decreasing from 13 days (IQR: 10.3–19.8) in 2005 to seven days (IQR: 6–11) in 2009. The LOS for laparoscopic and open procedure patients was seven days (IQR: 6–10) and 11 days (IQR: 9–15), respectively  of all procedures, followed by right hemicolectomy in 28.7% (95% CI:22.0–36.4%), total colectomy in 8.7% (95% CI: 5.3–14.1%), and abdominoperineal resection in 7.3% (95% CI: 4.1–12.7%). A further 10% (95% CI: 6.2–15.8%) included other colorectal surgery such as Hartmann's procedure and left hemicolectomy. Overall, 26% (95% CI: 19.6–33.6%) of operations were performed laparoscopically. The median operative duration was 167 minutes (IQR: 131–210). General anaesthesia was used in 60% (95% CI: 52–67.5%) of patients and a combination of general and neuraxial anaesthesia in 38.7% (95% CI: 31.3–46.7%). The use of general anaesthetic only increased from 53.3% in 2005 to 83.3% in 2009, with general and neuraxial anaesthesia, decreasing from 43.3% in 2005 to 16.7% in 2009 as shown in The median number of days to ambulation decreased from three days (IQR: 2-3) in 2005 to 1.5 days (IQR: 1-2) in 2009.Pharmacological prophylaxis was used in 98.7% (95% CI: 95.3–99.6%) and mechanical prophylaxis in 99.3% (95% CI: 96.3–99.9%) of patients. LMWH was used in 35.3% (95% CI: 28.1–43.3%) of patients and LDUH in 52.7% (95% CI: 44.7–60.5%). LDUH followed by LMWH was used in 10.7% of patients (95% CI: 6.7–16.6%). The pharmacological prophylaxis dose regimes utilised are shown in The duration of in-hospital pharmacological VTE prophylaxis decreased from 10 days (IQR: 4–12.5) in 2005 to 5.5 days (IQR: 3–8) in 2009 corresponding to decreasing length of stay. Pharmacological prophylaxis was given to 86% (95% CI: 79.5–90.7%) of patients postoperatively only compared to 12.7% (95% CI: 8.3–18.9%) receiving heparin preoperatively and postoperatively. Median time to operation for preoperative LMWH administration was 13 hrs (IQR: 8.0–17.8 hrs) and from operation for postoperatively only administration was 8.5 hrs (IQR: 5.7–23.3 hrs). Median time to operation from preoperative LDUH administration was 17.1 hrs (IQR: 12.2–24.6 hrs) and from operation for postoperatively only administration was 7 hrs (IQR: 5.1–9.3 hrs). The changing pattern over five years (2005 to 2009) in duration of pharmacological VTE prophylaxis in hospital and after discharge, is shown in ACCP and NHMRC guidelines for VTE prophylaxis recommend colorectal cancer surgery patients receive LMWH or LDUH for at least seven to 10 days postoperatively with consideration of extended prophylaxis for up to 28 days after discharge , 8. DuriMajor bleeding complications occurred in 4% (95% CI: 1.9–8.5%) of patients, 3.3% receiving LDUH and 0.7% LMWH .From the time of original admission to 12 months after discharge, the overall incidence of VTE was 2.4% (95% CI: 1.3–4.4%). Of these patients, 75% (95% CI: 40.9–92.9%) had a TNM stage greater than three and 62.5% (95% CI: 13.7–69.4%) did not receive VTE prophylaxis after discharge. The median number of co-morbities in this group was 4.5 (95% CI: 2–5.5). The proportion of VTE events at three months and at 12 months is shown in Of the 417 patients, 19.4% (95% CI: 15.9–23.5%) experienced at least one hospital readmission in the three months after discharge. At 12 months after discharge, 27.6% (95% CI: 23.5–32.1%) had at least one readmission. VTE accounted for 7.4% (95% CI: 3.4–15.2%), and 8.7% (95% CI: 4.8–15.3%) of readmissions in the first three and 12 months, respectively.The overall incidence of VTE in patients undergoing colorectal surgery for suspected or confirmed malignancy was found to be 2.4% out to 12 months, with all identified VTE events occurring following initial hospital discharge. More than half of these VTE events (1.4%) occurred within three months of discharge. The incidence of VTE in this study is lower than published figures and may underestimate the true incidence of VTE . Some paThe incidence of major bleeding complications found in this study (4%) is comparable to other studies and despite the difference in incidence of major bleeding complications between LDUH and LMWH in this study  many studies have demonstrated no significant difference in risk of bleeding between LDUH and LMWH , 14.P < .0001). The time to ambulation after surgery decreased by half, from a median of three days in 2005 to one and a half days in 2009, with earlier mobilisation likely decreasing risk of VTE. This may be partially attributable to a decrease in the use of combination general and neuraxial anaesthesia and an increased use of general anaesthesia alone allowing for earlier ambulation without adjunctive neuraxial anaesthesia. In patients found to have VTE, multiple recognised risk factors were present including advanced-stage cancer, multiple co-morbidities, and operative duration greater than two hours [Our patients' median length of stay decreased from 13 days (IQR: 10.3–19.8) in 2005 to 7 days (IQR: 6–11) in 2009 with patients undergoing a laparoscopic procedure having a significantly shorter LOS (wo hours . ChemothIn the period 2005 to 2009, the median duration of in-hospital pharmacological VTE prophylaxis fell from 10 days in 2005 to 5.5 days in 2009, corresponding with the fall in median LOS from 13 days in 2005 to seven days in 2009. In contrast, the percentage of patients receiving pharmacological VTE prophylaxis in the period after discharge increased dramatically from 6.7% in 2005 to 73.3% in 2009, with the main increase occurring in the period 2007-2008 which corresponds to the introduction of interventional strategies such as paper reminders placed in clinical notes for ordering of post discharge pharmacological prophylaxis in this high-risk group of patients .A systematic review of strategies to improve VTE prophylaxis in hospitals demonstrated that active interventions such as electronic decision-support systems and paper-based reminders were more effective than passive dissemination of guidelines, although the studies examined were not adequately powered to demonstrate a statistically significant reduction in the incidence of VTE .In conclusion, this study of colorectal surgery patients with suspected or confirmed malignancy demonstrated no in-hospital symptomatic VTE events. While all patients received VTE prophylaxis during admission, the occurrence of the majority of VTE events in the three-month period after discharge and the trend towards decreasing length of hospital stay highlights the importance of VTE prophylaxis in the period immediately after discharge. To minimise the occurrence of VTE after discharge, it is imperative to educate and support clinicians, allied health staff, and patients on the importance of VTE preventative strategies.


Because of geographical and periodical variation, we prompted to determine the demographic features and causative factors for febrile seizure in Rasht. In this cross-sectional study, all 6–month- to 6-year-old children with the diagnosis of febrile seizure admitted to 17 Shahrivar hospital in Rasht, from August, 2009 to August, 2010 were studied. Age, sex, family history of the disease, seizure types, body temperature upon admission and infectious causes of the fever were recorded. All statistical analysis was performed with SPSS software, version 16.Of the 214 children , 124 were boys and 109 had a positive family history. Complex seizures were seen in 39 cases. In patients with a complex febrile seizure, 59% had the repetitive type, 20.5% had the focal type and 20.5% had more than 15 minutes duration of seizures. Most of the repetitive seizures (78.3%) occurred in patients under 2 years old; the difference between under and over 2-year-old patients was statistically significant. Study results did not show significant differences between the two genders for simple or complex seizures. The mean body temperature upon admission was 38.2±1.32◦C (38.31±0.82 degrees in boys and 38.04±1.78 in girls). Upper respiratory infections were seen in most patients (74.29%). All cases of lower respiratory infections were boys. There was a statistically significant difference between boys and girls in causes of fever.Most of the children had a positive family history and the most common causative factor was upper respiratory infection. Febrile seizure is the most common type of convulsive disorder and one of the most prevalent cause of emergency hospital admission in children  Several In this cross-sectional study, the medical data of all 6-month- to 6–year-old children with the diagnosis of febrile seizure admitted to clinics or hospitalized in 17 Shahrivar hospital in Rasht, from August 2009 to August 2010, were studied.Patient’s data including age, sex, family history of disease, seizure types (simple or complex) and complex seizure subtypes such as focal, repetitive, or a duration of more than 15 minutes, body temperature upon admission, and infectious causes of fever were recorded in specific self-formatted questionnaires.All children with a seizure due to central nervous system infections, a past medical history of seizure, and co-orbidity with chronic diseases or electrolyte imbalance were excluded from our study. We obtained written informed consent from all parents for inclusion in the study. The Ethics Committee of Guilan University of Medical Sciences approved the study.Normality of data distribution was assessed by the Kolmogorov-Smirnov test. Discrete variables are expressed as counts (%) and compared using Chi-square tests. Continuous variables are expressed as mean ± SD and compared by means of the unpaired, two-sided t test. Adjusted odds ratios and 95% Wald confidence intervals were calculated based on these models.Statistical significance was set at P<0.05. SPSS 16 for Windows  was used for statistical analysis.We studied a total of 214 children with febrile seizure, of which 124 cases (57.9%) were male and 90 (42.1%) were female. The mean age of the patients was 25.24±15.40 months, and 128 children (59.8%) were under 2 years. The mean age for male and female were 25.62±15 and 25.13±16.11 months, respectively (P= 0.81). One hundred and nine children (50.9%) had a positive family history. Simple febrile seizures were seen in 175 patients (81.8%) and complex seizures in 39 cases (18.2%). Of the patients with complex febrile seizure, 23 cases (59%) had the repetitive type, eight cases (20.5%) had the focal type, and eight cases had more than 15 minutes duration of febrile seizures. Most of the complex seizure cases with repetitive type (78.3%) occurred in patients under 2 years old. In this aspect, the difference between the two age groups (under and over 2 years) was statistically significant (P=0.02). Study results did not show significant difference between two genders for simple or complex seizures.The mean body temperature upon admission was 38.2±1.32 degrees centigrade that was 38.31±0.82 degrees centigrade in boys and 38.04±1.78 degrees centigrade in girls (P =0.15). Data on patient’s underlying causes for fever are provided in Febrile seizure is the most common seizure in childhood . OccurriIn this study, 124 cases with febrile seizure were boys (57.9%) and the remainder were girls (42.1%). A definite male predominance was detected for febrile seizure in our study (p=0.21). These results are similar to the findings of a study conducted by Habib et al. in Pakistan; he found that the male gender had a 1.3 times greater risk of febrile seizure . This isMahyar et al. in 2010 found that gender is an important factor in febrile seizure; in his study, 66% of the infants with febrile seizure were boys . AshrafzIn this survey, 81.2% of the patients had simple and 18.2% had the complex form of febrile seizure. This was also stated by Hosseini Nasab et al. In his study on 460 infants with febrile seizure, simple and complex form of febrile seizure were 76/4% and 23/6%, respectively .n our study, 50.9% 0f affected children had positive family history of febrile seizure. In other Iranian studies, performed in Boushehr (59%), Kashan (55%) and Kerman (50%), positive family history was identified as most remarkable risk factor in these children , 20-21, Viral disease manifested as upper respiratory tract infection (URI) and gastroenteritis, is one of the causes of febrile disease. Khodapanahande in his survey in Tehran found that nonspecific viral disease is the main cause of febrile seizure, with a frequency of 82% . Mahyar In conclusion, in this study, the occurrence of febrile seizures was higher in boys than girls. In addition, most of the children had a positive family history of febrile seizure, and the most common causative factor was the upper respiratory tract infection. There was a statistically significant difference between boys and girls regarding the cause of fever. Repetitive type of complex seizure was seen mostly in patients less than 2 years; the difference between patients under and over 2 years was significant.


OR=4.83,95% CI=1.44-16.22), subjects who often went to bars for sexual partners , and subjects who had more than one sexual partner in the past 6 months  and had sex with fixed sexual partners in the past 6 months  were significantly associated with the rate of continued condom use in homosexual sex in the past 6 months. Unprotected sex and multiple sexual partners were more common among MSM in Suzhou city; furthermore, the prevalences of HIV infection and syphilis were relatively high. HIV preventive measures should be designed to address these risk factors and control the spread of HIV among MSM.A cross-sectional study using the snowball sampling method was conducted in May 2008 to investigate human immunodeficiency virus (HIV) infection status and related high risk factors among men who have sex with men (MSM) in Suzhou city of Jiangsu province. The researchers carried out a face-to-face questionnaire interview among MSM, and collected their blood samples to test for HIV and other sexually transmitted diseases (STDs). Among the 280 respondents, 91.1% had homosexual acts in the past 6 months and 87.5% had multiple homosexual partners; 46.4% had heterosexual sex in the past 6 months and 33.1% had multiple heterosexual partners. The rate of continued condom use was 44.3% in homosexual sex in the past 6 months, while the rate in heterosexual sex was 33.9%. Laboratory test results showed that the prevalences of HIV and syphilis were 7.1% (20/280) and 15.0% (42/280), respectively, but no HCV-positive person was found. In the multivariate logistic regression model, subjects with a monthly income of more than RMB ¥ 1,000 ( Men who have sex with men (MSM) are known to belong to one of the three high-risk groups for infection with human immunodeficiency virus (HIV)A cross-sectional study using the snowball sampling method and internet broadcast was conducted in May 2008 in Suzhou to cramp out MSM in accordance with the following standards: subjects who had settled in Suzhou for more than three months; subjects who had oral or anal homosexual behavior in the past year; subjects who aged 18 years and above. The study was approved by the Ethics Cominittee at each author's affiliated institutions and all subjects were enrolled with an informed consent.Treponema Palladium antibody and other STDs.Five mL of venous blood sample from the subjects were collected to test for HIV, HCV-antibody (Ab), Treponema Palladium gelatin agglutinate experiment method (TPPA). HCV antibody was prescreened by ELISA, and confirmed by the recombinant immune imprinting screening method (RIBA).HIV-Ab was prescreened by enzyme-linked immune sorbent test method (ELISA) and confirmed by Western blotting assay. The syphilis antibody was prescreened by rapid plasma response meat/toluene detection method (RPR/TRUST) and confirmed by the P < 0.10) significant in the bivariate analysis were considered for inclusion in multivariate logistic regression models.Data was doubly entered into a computerized database using EpiData 3.1 software. Statistical analysis was performed using Stata 10.0. Descriptive analysis was conducted on demographic and behavioral characteristics and syphilis infection. Variables  were unmarried; 81 (28.9%) were married; 5 (1.8%) were unmarried couples; 9 (3.2%) were divorced or widowed. Sixty-eight (24.3%) were natives of Suzhou; 72 (25.7%) were from other districts of Jiangsu province, and 140 (50.0%) were from other provinces. Two hundres and seventy-eight (99.3%) were Han nationality. Four (1.4%) finished primary school; 56 (20.0%) finished junior high school; 114 (40.7%) received senior high school or technical secondary school; 106 (37.9%) received junior college or above education. Fifteen (5.4%) reported no income; 5 (1.8%) had an income of ¥1000 per month or below, 93 (33.2%) had ¥1001-2000 per month, 80 (28.6%) had ¥2001-3000 per month, 40 (14.3%) had 3001-4000 per month, 47 (16.8%) had ¥4000 or above per month.The respondents had a relatively good knowledge of HIV/AIDS with an accuracy rate of 87.5%-98.6%, but for the question “whether mosquito will spread the AIDS virus”, it had a lower accuracy rate of 56.8%. As for HIV/AIDS attitude, among 280 MSM, 243 people (86.8%) thought that HIV/AIDS is much more horrible than other chronic diseases, and 232 (82.9%) considered using condoms to prevent HIV infection. Twenty-two (7.9%) still chose anal sex without condom though they knew that there was a high infection rate of HIV/AIDS. One hundred and fifty (53.6%) thought that they had no chance of being infected by HIV in the next year.The respondents had their first sexual behavior at an average age of 21.5±6.0 years. One hundred and twenty-four (44.3%) of them had their first sex act with man at an average age of 23.8±7.6 years. The respondents with homosexual orientation were 115 (41.1%), with heterosexual orientation were 12 (4.3%), and with bisexual orientation were 144 (51.4%), and 9 people (3.2%) had undetermined sexual orientation.Among 280 MSM, 255 people (91.1%) responded that they had anal sex with male partners in the recent six months with an average of 7.5 sexual partners. Two hundred and thirty-three people (87.5%) had 2 or more sexual partners. Among the respondents, 87 (34.1%) chose a general role as “inserter”, 39 (15.3%) chose “receiver”, and 129 (50.6%) chose both. For sex acts in the recent six months, 17 persons (6.7%) never used condom; 125 persons (49.0%) used condom sometimes; only 113 persons (44.3%) used condom regularly. For the last sex behavior, 201 persons (78.8%) used condom. One hundred and forty-nine (58.4%) responded that they had homosexual act with stable sexual partners in the recent six months, of which 60 (40.3%) had anal sex with fixed partners by regular condom use in the recent six months. Two hundred subjects (78.4%) had unfixed sexual partners, of which 104 (52.0%) had anal sex with unfixed partners by regular condom use in the recent six months.Among 255 respondents, 32 (12.5%) had commercial sexual acts in the recent six months with an average of 31.0 sexual acts. Fifteen respondents (46.9%) had 2 or more than 2 commercial sexual partners, 28 (87.5%) used condom in the last commercial sexual act, and 24 (75.0%) had commercial sexual acts with condom every time in the recent six months. At the same time, 65 persons (25.5%) offered commercial sexual acts in the recent six months with an average number of 48.3, and 58 (89.2%) offered commercial sexual acts to 2 or more than 2 sexual partners. Sixty (92.3%) persons used condom in the last commercial sexual act, and 52 (80.0%) had commercial sexual acts with condom regularly in the recent six months.Among 280 MSM, 130 (48.7%) responded that they had heterosexual acts with an average of 1.7 and 43 (33.1%) have 2 or more than 2 heterosexual partners. Sixty-three (48.5%) used condom during the last heterosexual act. Forty-seven (36.2%) never used condom in the recent six months during the last heterosexual acts, and 39 (30.0%) sometimes used, and only 44 (33.9%) used condom regularly.CI=4.41-10.82), 42 persons were positive for syphilis with a positive rate of 15.0% (95%CI=11.02-19.73), and no persons were found positive for HCV in the screening.Blood samples from the subjects were collected for laboratory testing. It was confirmed that 20 persons were HIV positive with a positive rate of 7.1% .Single factor χP < 0.10) in bivariate analysis were considered for inclusion in a multiple logistic regression model; as a result, variables that entered the multiple factors logistic regression model were as follows: monthly income more than RMB¥ 1,000 , often going to the bars for sex , having more than one sexual partner in the past 6 months  and having sex with fixed sexual partner in the past 6 months  (Those variables that were significant (P < 0.05).The analysis results showed that statistically significant variables of HIV infection included the number of homosexual partners and having unfixed homosexual partners within six months shown in P < 0.1 in the above single factor χ2 analysis were analysed by multiple factors logistic regression model; as a result, no variable entered the multiple factors logistic regression model.The factor variables whose result was et alet al. result. The reason might be that conservative sex concept in Suzhou led MSM to develope a sense of their sex orientation late.This survey of MSM in Suzhou showed that the average age of the MSM was 28.1 years, and the average age at first sex with man was 23.8 years, which was older than that in other researchesThe awareness of knowledge on HIV/STDs by MSM in Suzhou in this research was 87.5%-98.6%, which is similar to that of other regionset alIn the aspects of HIV/AIDS related behaviors, firstly, the rate of condom use within Suzhou MSM was apparently higher than that of other citiesEarly researches showed that subgroups of MSM looking for sexual partners through the Internet had more sexual partners and more unprotected homosexual behaviorset al.et alCommercial sexual behavior and heterosexual behavior group are two subgroups of MSM and they are more likely to spread AIDS because most of them had multiple sex partners and are engaged in unprotected insert sexual behaviorsFor laboratory tests, the HIV infection rate of MSM in Suzhou was 7.1%, which is higher than 5.8% reported by the 2006-2007 research in Jiangsu, and the infection rate of syphilis is 15.0%, which is lower than the latter (27.7%). This suggestes that though Jiangsu province is an area with low HIV infection rate, research and intervention measures aimed at MSM still need to be carried out early. Early effective prevention and intervention play an important role in reducing the infection rate of syphilis. While infection of HIV has many complex related factors, and it will be a long and systemic project to prevent and control, it can be predicted that infection of AIDS in the target population will increase in the short run. In this survey, multiple factors logistic regression analysis of HIV infection showed that no factor is related with HIV infection, but infection of syphilis and HIV are positively correlated. It shows that infections of syphilis and other STDs make MSM more susceptible to HIV. In addition, many researches have proved the possibility that HCV can be spread through sex and have a high infection rate especially among the high risk population. Due to the quality of HCV detection, we did not find any HCV positive subject in our research.There are also some drawbacks in our research. For example, we adopt a kind of nonrandom and improbability snowball sampling method, which impairs the validity of the research. In fact, we can use respondent driven sampling (RDS) method, which is now widely used in MSM and other populations that are difficult to keep track of. With this, we can enlarge the number of samples to do more profound research that can cover every sub-MSM population so that we can describe the AIDS related behavior characteristics and prevalent condition of MSM in the whole Suzhou city, and even the whole Jiangsu province. Further researches on the related hazards are needed to offer more evidence for HIV/AIDS prevention and control.


Radical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival.A total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2 ± 3.7 years, participated in the study. The mean follow-up period was 2.6 ± 1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively. The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters.The perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome.RC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results. Muscle-invasive bladder cancer incidence increases with age and peaks in the octogenarians ,2. Even Increased surgical experience and improvements in surgical techniques are constantly expanding the indications for aggressive treatment. This fact provided the rationale for our study, which attempted to investigate the feasibility of RC in these high-risk patients and establish a potential benefit on cancer-specific survival in the long term.We reviewed the files of 81 patients, 61 men and 20 women, with a mean age of 79.2 years (SD = 3.7 years) (range 75–95 years). All patients, after providing informed consent, underwent RC and pelvic lymphadenectomy from 2000 through 2009. Ethical approval was not required due to the retrospective nature of the study, as stated by our institutions scientific committee. The clinical and demographic characteristics of the patients are shown in Table Perioperative complications were defined as complications occurring within the first 10 postoperative days. 90-day morbidity and mortality were also recorded. The Martin criteria for standardized reporting of complications were used  Table 22. The coQuantitative variables are expressed as mean (±SD) or as median values (interquartile range). Qualitative variables are expressed as absolute and relative frequencies. Life table analyses were used to calculate cumulative survival rate (standard errors) for specific time intervals. The prognostic value of each variable was first assessed by univariate Cox regression analysis. Variables that showed significant association with the outcome were included in the multivariate Cox proportional-hazard model in a stepwise method, in order to determine the independent predictors for morbidity and oncological outcome. The assumption of proportional hazards was evaluated by testing for interaction with a continuous time variable. Kaplan – Meier survival estimates for soft and hard events were graphed over the follow-up period. All reported p values are two-tailed. Statistical significance was set at p < 0.05 and analyses were conducted using the SPSS statistical software (version 17.0).The mean follow-up period was 2.6 ± 1.6 years with median equal to 2.4 years (interquartile range from 1.2 to 3.9 years). During the follow-up period, the perioperative morbidity rate was 43.2% N = 35), 90-day morbidity rate was 35.8% (N = 29), the perioperative and overall mortality rates were 3.7% and 21.0%, respectively, while 6 patients had metastasis (7.4%). In salvage RC, perioperative morbidity rate was 45.4%, 90-day morbidity rate reached 36.4%, while perioperative mortality was 9%. Positive nodes were found in 25.9% of the patients. The mean length of hospitalization was 13.0 ± 7.3 days and 14.8% of the patients had an age-adjusted Charlson comorbidity index (ACCI) more than six. Table , 90-day The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7% [Standard Error (SE) = 3.6%], 77.5% (SE = 4.8%), 70.4% (SE = 5.5%) and 62.3% (SE = 7.3%), respectively. Both univariate and multiple analysis concerning death or metastasis  and it could be attributed to poor healing capacity and poor patient hygiene. In order to avoid this kind of complication, we now routinely use tension sutures along with Nylon sutures or clips for wound closure at the end of the operation, which are removed approximately one month later.The complication rates did not vary between salvage and primary RC. The main difference was that perioperative mortality was significantly higher in the salvage RC (9% vs. 3.7%), which was somewhat expected, due to the nature of the disease and the performance status of the patient at the time of the operation. The above observation is in accordance to other authors ,15. FurtThe selected type of urinary diversion does not seem to alter the morbidity/mortality outcome, as shown in other studies as well ,16. It iCancer-specific survival is another major concern when the decision to perform RC in an octogenarian should be taken, as the reported results are rather controversial. Two retrospective studies, reviewing a total of approximately 1120 patients have reported unfavourable oncological outcomes in elderly patients ,19. In tAge should not hamper RC, particularly when it takes place in specialized, high-volume centers. The reported complication rates of this particular group of patients, especially when standardized with validated methodologies, are acceptable. Strict selection of non obese patients, with non metastatic disease and an ACCI less than six, may result in a better postoperative outcome.The authors declare that they have no competing interests.IA performed surgical procedures, participated in the study concept and design and critically revised the manuscript. SIT conceived the study, performed statistical analysis, drafted the manuscript, analyzed and interpreted the data. KGS performed surgical procedures, assisted in the study concept and design and revised the manuscript. AA participated in the acquisition of data. AK performed surgical procedures and provided patient data. AB participated in the acquisition of data. VM participated in the acquisition of data. DM performed surgical procedures, assisted in the study concept and design and revised the manuscript. CAC performed surgical procedures, assisted in the study concept and design and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/12/18/prepub


Adequacy of fluid resuscitation remains a cornerstone of early burn management. The Parkland formula - that is, administration of 4 ml/kg/% total of the body surface area (TBSA) burned with Ringer's lactate for the first 24 hours post injury - has been used for decades. The purpose of this study was to evaluate the effect of adherence with the Parkland protocol and its impact on the severity of organ failure during the first week post injury using the Sequential Organ Failure Assessment (SOFA) score.P < 0.05 was considered statistically significant).We conducted a retrospective review of burns' resuscitation data, from 2000 to 2007, on 101 adult patients (aged ≥16 years) admitted within the first 24 hours following injury, with a %TBSA burned of 20 or more. A classification of patients into four groups, according to fluids administered, was done for comparison between these groups. The SOFA score was calculated daily for the first week after admission. The neurological component of SOFA was left out because of the difficulty to assess the actual Glasgow Coma Scale in sedated patients. Organ failures were defined by partial SOFA ≥3. Data are expressed as median (Q1 to Q3) and are analyzed using the chisquare test (P = 0.03). The amount of fluids administered had no impact on the incidence of cardiovascular (P = 0.89), renal (P = 0.11), liver (P = 0.52) and coagulation (P = 0.86) failure.A total of 62 patients with complete data on fluid administration were included in the analysis. Median age was 41 (28 to 54) years, median TBSA burned was 35.5 (25 to 50); median ICU stay was 38 (12 to 62) days and 13 (21%) patients died. Ten patients suffering from inhalation injury were excluded from further analysis. Median fluids administered was 4.9 (4.1 to 6.2) ml/kg/%TBSA at 24 hours. Five patients received <3. 5ml/kg/%TBSA, 15 between 3.5 and 4.5 ml/kg/%TBSA, 17 between 4.5 and 6 ml/kg/%TBSA and 15 patients >6 ml/kg/%TBSA. No differences existed between groups concerning the cause and surface of injury, age, sex, and comorbidities. Compared to others, patients who received >6 ml/kg/%TBSA had a significant increase in respiratory failure (This single-centre retrospective study indicates that fluid resuscitation volumes frequently overcome those previously established by the Parkland protocol. This fluid over-resuscitation may have deleterious effects on patient outcome by increasing the incidence of respiratory failure.


Purpose. To assess the efficacy and safety of adalimumab in patients with juvenile idiopathic arthritis (JIA) and associated refractory uveitis. Design. Multicenter, prospective case series. Methods. Thirty-nine patients (mean [SD] age of 11.5 [7.9] years) with JIA-associated uveitis who were either not responsive to standard immunosuppressive therapy or intolerant to it were enrolled. Patients aged 13–17 years were treated with 40 mg of adalimumab every other week for 6 months and those aged 4–12 years received 24 mg/m2 body surface. Results. Inflammation of the anterior chamber (2.02 [1.16] versus 0.42 [0.62]) and of the posterior segment . The mean (SD) macular thickness at baseline was 304.54 (125.03) μ and at the end of follow-up was 230.87 (31.12) μ (P < 0.014). Baseline immunosuppression load was 8.10 (3.99) as compared with 5.08 (3.76) at the final visit (P < 0.001). The mean dose of corticosteroids also decreased from 0.25 (0.43) to 0 (0.02) mg (P < 0.001). No significant side effects requiring discontinuation of therapy were observed. Conclusion. Adalimumab seems to be an effective and safe treatment for JIA-associated refractory uveitis and may reduce steroid requirement. Uveitis is a well-known extra-articular manifestation of spondyloarthritides, which may lead to severe functional impairment . Childhoα) blocking agents  have been used to treat chronic refractory uveitis in childhood [α antagonist, has shown remarkable efficacy in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Crohn's disease, and plaque-type psoriasis. Currently, there is a large experience of the beneficial effects of adalimumab in the treatment of these conditions in daily practice. Since 2008, adalimumab has been approved for the treatment of active juvenile idiopathic arthritis (JIA).JIA-associated refractory chronic uveitis is a challenge for treatment. Topical and systemic corticosteroids are the first-line standard therapy, often reinforced by conventional disease-modifying antirheumatic drugs (DMARDs) including a variety of immunomodulatory agents, but methotrexate remains the most commonly used drug –12. Durihildhood  and, parhildhood , 17. Adaα treatment for sight-threatening childhood uveitis, adalimumab was more efficacious than infliximab in maintaining remission of chronic childhood uveitis for over 3 years [α inhibitor [Adalimumab has shown promising results in controlling intraocular inflammation, even though this has been used primarily as a rescue therapy for refractory uveitis . Open-la 3 years . In rece 3 years . In recenhibitor .A prospective multicenter study was design to assess the efficacy and safety of adalimumab therapy in a cohort of patients with JIA and associated uveitis who were treated with adalimumab in daily practice.A prospective open-label, noncomparative, and multicenter study was conducted in the outpatient clinics of the services of ophthalmology or uveitis units of 10 centers throughout Spain and 1 center in Latin America  in daily practice conditions. The objective of the study was to assess the efficacy and tolerability of adalimumab for treating children and adolescents with uveitis in conjunction with JIA. The diagnosis of JIA was based on the 2001 revised International League Against Rheumatism (ILAR) classification criteria . All diaα inhibition. Patients diagnosed with latent tuberculosis, defined as a PPD skin conversion consisting of an induration of 5 mm or larger without radiographic or clinical evidence of disseminated or pulmonary disease, received antituberculosis prophylaxis at least 3 weeks prior to the first dose of adalimumab.All patients underwent a protein-purified derivative (PPD) skin test and chest radiography before enrollment because of the risk of tuberculosis reactivation associated with TNF-2 body surface area up to a maximum single dose of 40 mg s.c. every other week). The volume of injection is selected according to the weight and height of the patient. Patients (or parents in case of young children) were instructed by a specialized nurse in self-administration of adalimumab.In all patients, treatment with adalimumab was initiated because of active refractory uveitis. Children and adolescents between 13 and 17 years of age were treated with 40 mg of adalimumab , subcutaneously (s.c.) every other week for 6 months. For children aged between 4 and 12 years, doses were administered as indicated in the product label  was measured according to the ETDRS protocol adapted by the Age Related Eye Disease Study . Three lThe immunosuppression load was assessed with a semiquantitative scale for each medication as described by Nussenblatt et al. . The graMacular thickness was measured by optical coherence tomography (OCT) . Changes in the mean 1 mm central foveal retinal thickness served to evaluate the reduction in the cystoid macular edema (CME).Statistical Analysis. Categorical data are expressed as absolute number and percentages and continuous data as mean and standard deviation (SD). Continuous variables were analyzed with the paired Student's t-test  and qualitative variables (degree of intraocular inflammation) with the Wilcoxon signed-rank test. Statistical significance was set at P < 0.05. The analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 12.0 for Windows.A total of 39 patients, 11 boys and 28 girls, with a mean (SD) age of 11.5 (7.9) years were included in the study. All patients presented initially with arthritis. The age at diagnosis of arthritis ranged between 18 months and 6 years, with a median of 4.4 years. Manifestations of uveitis developed approximately 8 months after the diagnosis of JIA.All patients were followed for at least 6 months. Twenty-nine (74.4%) patients had chronic anterior uveitis, 1 (2.6%) intermediate and anterior uveitis and 9 (23.1%) panuveitis (anterior with secondary posterior uveitis). The right eye was involved in 2 (5.1%) patients, the left eye in 5 (12.8%), and both eyes in the remaining 32 (82.1%) patients.P < 0.001). Differences in the mean degree of intraocular inflammation of the posterior chamber were also statistically significant (P < 0.005).Changes of outcome variables associated with adalimumab therapy are shown in P = 0.226).The visual acuity improved by −0.3 logMAR (+15 letters) in 4 (12.5%) eyes out of 32 eyes, remained stable in 26 (81.2%) eyes, and worsened by +0.3 logMAR (−15 letters) in 2 (6.25%) eyes at the end of follow-up. The baseline visual acuity was +0.30 ± 0.32 (mean ± SD) logMAR and +0.24 ± 0.35 logMAR at the end of follow-up. There was no statistically significant difference between the mean baseline visual acuity and the mean visual acuity at the end of follow-up (μ and at the end of follow-up was 230.87 (31.12) μ. There was a statistically significant difference between pretreatment and final macular thickness (P < 0.014)  had CME at baseline, and at the end of follow-up, there was complete resolution of CME in all cases . The mea< 0.014) .P < 0.001).Baseline immunosuppression load was 8.10 (3.99) as compared with 5.08 (3.76) at the final visit. There was a significant difference in the mean immunosuppression load between baseline and end of follow-up (P < 0.001).Treatment with adalimumab was also associated with a decrease in the mean dose of corticosteroids from 0.25 (0.43) at the pretreatment visit to 0 (0.0.2) mg at the end of follow-up  patients experienced reactivation of uveitis, which was severe in only 1 patient (3.1%), who discontinued the adalimumab therapy and improved with infliximab treatment. The remaining 2 patients did not discontinue the adalimumab therapy because the inflammation was controlled with periocular steroid injection of the affected eye.This prospective study carried out in a clinical series of 39 children and adolescents with JIA-associated uveitis confirms the value of adalimumab as a treatment option in patients who were poorly responsive to conventional therapy for uveitis. The effectiveness of adalimumab was demonstrated by a statistically significant decrease of anterior chamber and vitreous cavity degree of inflammation, reduction of macular thickness, and decrease of the immunosuppression load.α appears to play a role in the pathogenesis of uveitis [α blockade is a rational therapy for uveitis refractory to standard treatment [Most reported treatment studies in pediatric uveitis are retrospective case series, which may be explained by the relative rarity of uveitis associated with JIA, urgency of treatment to prevent complications, difficulty in examining younger children, and the lack of controlled clinical trials . The cou uveitis –31 and treatment .α blocker for childhood uveitis and the preferred biologic drug for the treatment of uveitis associated with JIA [α collected in a multinational survey, and 9 patients reported by Vazquez-Cobian et al. [Adalimumab is currently considered the most efficacious TNF-with JIA . In thiswith JIA , 6 patiewith JIA , 3 patiewith JIA  among 47n et al. . Other cn et al.  and a ren et al. . Findingn et al. . In thisα antagonists  appear to have similar efficacy in rheumatoid arthritis (JIA), but this does not appear to be the case with uveitis where infliximab seems to be more effective than etanercept, and adalimumab more effective than infliximab. In an open-label prospective comparison of infliximab and adalimumab in 33 children with refractory noninfectious uveitis, 22 of them with associated JIA, at 40 months of follow-up, 60% of children on adalimumab compared to 18.8% of children on infliximab were still in remission on therapy [The three TNF- therapy .In summary, treatment with adalimumab for at least 6 months was associated with improvement of symptoms and decrease in inflammatory activity in 39 patients with refractory uveitis associated with JIA. It also allowed a significant reduction of concomitant immunosuppressive therapies.


Computational prediction of the 3D structures of molecular interactions is a challenging area, often requiring significant computational resources to produce structural predictions with atomic-level accuracy. This can be particularly burdensome when modeling large sets of interactions, macromolecular assemblies, or interactions between flexible proteins. We previously developed a protein docking program, ZDOCK, which uses a fast Fourier transform to perform a 3D search of the spatial degrees of freedom between two molecules. By utilizing a pairwise statistical potential in the ZDOCK scoring function, there were notable gains in docking accuracy over previous versions, but this improvement in accuracy came at a substantial computational cost. In this study, we incorporated a recently developed 3D convolution library into ZDOCK, and additionally modified ZDOCK to dynamically orient the input proteins for more efficient convolution. These modifications resulted in an average of over 8.5-fold improvement in running time when tested on 176 cases in a newly released protein docking benchmark, as well as substantially less memory usage, with no loss in docking accuracy. We also applied these improvements to a previous version of ZDOCK that uses a simpler non-pairwise atomic potential, yielding an average speed improvement of over 5-fold on the docking benchmark, while maintaining predictive success. This permits the utilization of ZDOCK for more intensive tasks such as docking flexible molecules and modeling of interactomes, and can be run more readily by those with limited computational resources. Interactions between biomolecules are crucial to the function of biological systems, forming the basis of normal and aberrant cellular behavior, as well as defense against external pathogens. To fully understand these interactions, atomic-level descriptions of the structures of their binding interfaces are essential. While the structures of many protein-protein complexes have been characterized experimentally via x-ray crystallography and deposited in the Protein Data Bank PDB; , the majThe success of protein-protein docking algorithms in the past decade has given rise to several exciting developments in the field. This includes addressing molecular flexibility during binding by “cross-docking” ensembles representing snapshots of mobile structures Previously our laboratory developed the program ZDOCK, which uses a grid-based representation of two proteins and a 3-dimensional (3D) fast Fourier transform (FFT) to efficiently explore the rigid-body search space of docking positions To reduce this computational burden and make proteomic scale docking and ensemble docking approaches more tractable, we have developed a new version of ZDOCK that retains the predictive accuracy of ZDOCK 3.0 while vastly improving its computational performance. This was achieved by integrating an FFT library that was designed to improve 3D FFT performance in vivo (e.g. an antibody in an antibody/antigen interaction).The ZDOCK algorithm, which followed from initial efforts in FFT-based protein docking ZD1. Center receptor coordinates at origin based on center of mass.ZD2. Center ligand coordinates at origin based on center of mass.ZD3. Select cubic grid size to contain centered molecules for FFT.ZD4. Discretize receptor, assigning scores to 3D grid(s) of complex numbers.ZD5. Rotate input ligand to random orientation, if specified.ZD6. Rotate ligand to Euler angles from uniformly distributed set, and discretize.ZD7. Perform 3D FFT to compute convolution between ligand and receptor grids, and select top scoring position from the resultant grid.ZD8. Repeat steps 6–7 for a total of 3,600 ligand rotations (15° angular sampling) or 54,000 ligand rotations (6° angular sampling).Here we present major improvements to ZDOCK's initial orientation and FFT procedures (bold steps above), while not modifying the discretization protocols that embody the ZDOCK scoring function. Previous ZDOCK versions and their scoring terms include: ZDOCK 1.3 Modification of ZDOCK to improve its efficiency consisted of the following successive improvements:Integrating the Conv3D library. This entailed replacing the standard FFT library calls  for performing 3D convolution. Previously, ZDOCK discretized the receptor and ligand (the two input proteins) onto two cubic  3D grids. The Conv3D library, which is based on FFTW (http://www.fftw.org), and is optimized specifically for high efficiency convolution of 3D molecular structures Optimal centering of the input proteins. We further optimized ZDOCK by reducing the grid sizes of the receptor and ligand through careful selection of the molecular centers for grid placement. Prior to discretization onto the grid in ZDOCK, the input receptor and ligand are translated from their original coordinates to the origin (Steps ZD1 and ZD2 above). This translation was formerly selected using the molecules' centers of mass, but this can be non-optimal, particularly where a protein's mass distribution is not even. In the current ZDOCK implementation, we compute the receptor's maximal dimensions along each Cartesian axis and use the halfway points in each dimension for its grid center. For the ligand, which rotates through a series of angles during ZDOCK, we calculated its center as the origin of a bounding sphere using the algorithm proposed by Ritter Rotation of the receptor. Another improvement of ZDOCK is the use of a rotated receptor with respect to its input angular orientation. This gives improved efficiency versus a receptor with an input rotation that would leave excess unoccupied grid points when discretized onto a rectangular grid. To select this receptor rotation, ZDOCK iterates through 3,600 evenly distributed Euler angles  and evaluates the grid size required for each rotated receptor. The angle with the minimum required grid size is then chosen for input receptor rotation.Switching of the ligand and receptor. In the past, ZDOCK has kept the user-specified receptor fixed during ZDOCK execution, while rotating the ligand and re-discretizing it for each rotational angle. In the current ZDOCK version, this has been modified so that the receptor and ligand can be switched dynamically during ZDOCK execution. This switch is evaluated at the beginning of ZDOCK execution, by calculating the minimum grid required by the switched receptor and ligand , and comparing with the grid size from the original receptor and ligand. Based on the grid size comparison, either the original receptor will be fixed, or the ligand and receptor will be switched so that the ligand will be fixed and bounded by a rectangular grid.We previously released ZDOCK 2.3 and 3.0 with the Conv3D library (Step 1) as interim versions, named ZDOCK 2.3.1 and ZDOCK 3.0.1 respectively. The current releases include Steps 1–4 and are ZDOCK 2.3.2 and ZDOCK 3.0.2. Due to the input rotation of the receptor and the possible switching of the ligand and receptor, the ZDOCK output file format required slight modification of its header format, and consequent updating of the code to create ZDOCK predictions (create_lig) from the output file. However, the create_lig program still generates structural predictions with the receptor fixed with respect to the coordinates of the input PDB file, so that the internal optimization of the receptor and ligand coordinates for ZDOCK discretization are not visible to the end user.We also introduced a command line flag in ZDOCK (“-F”) to provide users the option of keeping the input receptor fixed (not rotated or switched with the ligand) during ZDOCK execution, resulting in the same ZDOCK output file format as previous versions. This entails Steps 1 and 2 (without Steps 3 and 4), and can be used for improved performance versus the base ZDOCK version (2.3 or 3.0) when users require the original ZDOCK output file format for their post-processing pipeline.http://www.gnuplot.info), and molecular structures were visualized using PyMOL (http://www.pymol.org).Data plots were generated using gnuplot (After updating ZDOCK versions 3.0 and 2.3 with the Conv3D FFT library and improved molecular representation (detailed in the Implementation section), we tested these new versions (3.0.2 and 2.3.2) for their computational efficiency using all 176 unbound test cases of protein-protein docking Benchmark 4.0 The most dramatic improvements were seen for ZDOCK 3.0.2, with 18.9 minutes average running time for the docking benchmark, from an original average running time of 167.1 minutes. This is nearly three times less than the average running time for ZDOCK 2.3 on the docking benchmark. On average, this version had an 8.6-fold improvement in running time versus ZDOCK 3.0; this was significantly higher than the 6.4-fold improvement from Conv3D alone (ZDOCK 3.0.1), though integrating Conv3D was evidently responsible for the majority of the running time improvement. Required memory concomitantly was reduced for these ZDOCK improvements, with less than half of the memory for ZDOCK 3.0 required, on average, by ZDOCK 3.0.2 .Mirroring the improvements for ZDOCK 3.0, the running time and memory usage of ZDOCK 2.3 were also improved via these library and discretization modifications, although to a lesser extent (5.5-fold versus 8.6-fold improvement in running time). While ZDOCK 2.3 has over three times faster average running time on the docking benchmark versus ZDOCK 3.0, ZDOCK 2.3.2 is still over twice as fast as ZDOCK 3.0.2.To ensure that the predictive accuracy of ZDOCK was maintained during optimization, we measured the success rates and the average number of hits for the original and updated versions of ZDOCK . As befoAs shown on a previous version of the docking benchmark To examine the extent of the running time improvement among individual cases, we compared running times for ZDOCK 3.0 with ZDOCK 3.0.2 for all 176 Benchmark 4.0 test cases , and somAlso evident is the clustered nature of running times for ZDOCK 3.0, as seen in the horizontal bands in An individual example of a test case with dramatic speed improvement is shown in These new versions of ZDOCK can be utilized more readily by those with limited computing resources, as well as those who are addressing challenging areas at the forefront of structural prediction, such as molecular flexibility and 3D network modeling. In fact, ZDOCK 3.0  was used to predict the structure of the yeast interactome using a large supercomputing cluster Others have recently presented algorithms that perform fast rigid-body protein docking using FFT approaches. Notably, the program Hex, which uses spherical harmonics rather than a 3D Cartesian grid to represent proteins, but does not contain atomic pairwise potential terms as in ZDOCK 3.0.2, was optimized using graphical processors to achieve very high docking efficiency http://zdock.bu.edu), which at present uses ZDOCK 2.3 as the computational requirements of ZDOCK 3.0 precluded its use in the server framework.Future work will include the development and validation of ensemble and cross-docking approaches using ZDOCK 3.0.2, as well as incorporating it into the ZDOCK server Click here for additional data file.Table S2Predictive performance of ZDOCK 3.0, 3.0.1, 3.0.2f and 3.0.2 for the test cases in Benchmark 4.0.(PDF)Click here for additional data file.Table S3Running times of ZDOCK versions 2.3, 2.3.1, 2.3.2f, and 2.3.2 for the test cases in Benchmark 4.0.(PDF)Click here for additional data file.Table S4Running times of ZDOCK versions 3.0, 3.0.1, 3.0.2f, and 3.0.2 for the test cases in Benchmark 4.0.(PDF)Click here for additional data file.


Pain is one of the most common reasons why patients visit the Emergency Department (ED) and is a healthcare problem for patients ,2. The pP < 0.05 was considered significant.A purposive sample of 100 patients and 36 nurses in the triage and clinical area within the ED was selected from 5Azar Hospital in Gorgan. The questionnaire included two components: participant characteristics and the Numeric Rating Scale (NRS). A questionnaire was administered twice to each patient. In triage the patients were asked to rate their pain intensity. Separately, the nurses assessed the patient's pain intensity. This process was repeated with the same patients after referring them to a clinical area within the ED, but the nurses were different. Gathered data were described by frequency distribution tables and analyzed by Wilcoxon, Mann-Whitney and Spearman tests. P < 0.001). In the clinical area, patients' scores were also significantly higher than nurses 7.36 ± 2.56 and 5.94 ± 2.33, respectively (P < 0.001). Nurses significantly underestimated pain on the NRS. See Table Most of the patients were male 61%), with mean age of 39.16 ± 16.83 years. Fifty-four percent of the patients had chronic pain. Most of them had a diagnosis of abdominal pain and chest pain (61%). In the triage, the mean nurses' pain intensity score was significantly lower than patients' score (7.60 ± 2.1 vs. 9.13 ± 1.26), as significant differences in mean scores were observed (%, with mThe findings have implications for the management of patients' pain by highlighting the need for more accurate pain assessment. Further research is required to elucidate the way in which nurses and patients conceptualize pain and to understand better the process of pain assessment in clinical nursing practice.


Injectable route seems to be the most frequently used in health facilities in a resource-limited setting.In order to better understand this under investigated issue, we conducted a longitudinal study of DAR use in the general pediatric ward of the Gabriel Touré Hospital to Bamako during 6 months.We are interested in the routes of administration applied to a population of 300 children with a sex ratio (M / F) = 1.3. Their average age was 2 years ± 1. Presumed diagnoses underwent a change from admission to discharge, both in frequency and formulation. Malaria (37.4% vs 39.7% at 72 hours), pneumonia (19% vs 20% at 72 hours), and the nephrotic syndrome (2.2% vs. 5.1% in 72 hours) were most commonly mentioned. Treatments prescribed for the presumed diagnosis were administered parenterally in 76.6% of cases at admission, in 70% 72h hours after admission and in 36.3% at discharge. The following complications were noted: inflammation of the catheter puncture sites , abscess at the site of intramuscular injection (2.1%). The mean duration of hospitalization was 7.6 ± 3.7 days and mortality was 11%.Injection is the most widely used in the pediatric unit III for the most common pathologies. A detailed study would be needed to assess the adequacy of the diagnostic hypotheses and routes of administration. The high number of injections exposes staff and patients to risks.None declared


Pituitary stalk interruption syndrome (PSIS) is characterized by the absence of pituitary stalk, pituitary hypoplasia, and ectopic posterior pituitary. Due to the rarity of PSIS, clinical data are limited, especially in Chinese people. Herein, we analyzed the clinical characteristics of patients diagnosed with PSIS from our center over 10 years.We retrospectively analyzed the clinical manifestations and laboratory and MRI findings in 55 patients with PSIS.Of the 55 patients with PSIS, 48 (87.3%) were male. The average age was 19.7±6.7 years and there was no familial case. A history of breech delivery was documented in 40 of 45 patients (88.9%) and 19 of 55 patients (34.5%) had a history of dystocia. Short stature was found in 47 of 55 patients (85.5%) and bone age delayed 7.26±5.37 years. Secondary sex characteristics were poor or undeveloped in most patients. The prevalence of deficiencies in growth hormone, gonadotropins, corticotropin, and thyrotropin were 100%, 95.8%, 81.8%, 76.3%, respectively. Hyperprolactinemia was found in 36.4% of patients. Three or more pituitary hormone deficiencies were found in 92.7% of the patients. All patients had normal posterior pituitary function and absent pituitary stalk on imaging. The average height of anterior pituitary was 28 mm, documented anterior pituitary hypoplasia. Midline abnormalities were presented in 9.1% of patients.The clinical features of our Chinese PSIS patients seem to be different from other reported patients in regarding to the higher degree of hypopituitarism and lower prevalence of midline defects. In addition, our patients were older at the time of case detection and the bone age was markedly delayed. We also had no cases of familial PSIS. Pituitary stalk interruption syndrome (PSIS) is characterized by an absent pituitary stalk on MRI, hypoplasia of the anterior pituitary gland, and ectopic posterior pituitary Since PSIS is a relatively newly recognized disorder with the introduction of MRI, the exact prevalence is uncertain. Most population studies related to PSIS are from the western hemisphere Over the past decade we collected 55 cases of Chinese patients with PSIS. In the present study, we analyzed the clinical presentations and laboratory and imaging data. This report represents the largest group of Chinese or Asian PSIS patients studied to date.The 55 patients with PSIS came from different parts of China, accounting for 21.9% of hospitalized hypopituitary patients diagnosed in our hospital during the same period. The ratio of male to female was 6.9∶1. The average age was 19.7±6.7 years . There was no documentation of consanguineous parents and familial history in any of the cases. The fetal position was not clear for 7 patients, and 3 patients was born by Caesarean; 5 patients presented with head presentation  and 40 patients experienced breech delivery or footling delivery , among them 19 patients had the history of dystocia . Sex chromosome findings matched gender phenotype.The clinical manifestations are summarized in Only 2 patients in this group of patients had even partial sex development and most patients were lack of sexual development. There were 5 cases that were not identified as having PSIS until they presented to the clinic for absent development of secondary sexual characteristics after pubertal age. The male patients exhibited no pubertal development, absent pubic and axillary hair, lack of adult male larynx development. The mean (±SD) testicular volumes were 2.21±1.94 ml (right) and 2.27±2.04 ml (left), respectively. The mean (±SD) length of flaccid penis was 3.48±1.29 cm. The prevalence of microphallus was 23.4%. Three patients had cryptorchidism, accounting for 6.3% of the male patients. Most of the female patients also exhibited poor secondary sexual characteristic development–including: absent pubic or axillary hair, hypoplasia of mammary glands, infantile uterus or primordial uterus, ovarian dysgenesis, non-development of labia majora and labia minora. However, a few patients had axillary hair and breasts were in Stage B3 (Tanner Staging 5 system), and pubic hair was in Stage P3 (Tanner Staging 5 system); labia majora and labia minora showed pigmentation, but they had an infantile uterus. All female patients had primary amenorrhea.In addition to relatively short stature and delayed or poor sexual development compared to normal peers, some patients were troubled by fatigue and hypodynamia and were more susceptible to upper respiratory infections. However, most of the patients had intelligence within the normal range, although their school records tended to reflect slightly lower performance.No patient complained of thirst, polydipsia or polyuria. The mean (±SD) fasting plasm glucose was 4.52±0.42 mmol/L and the mean (±SD) cholesterol was 3.81±0.45 mmol/L.Anterior pituitary function was evaluated with basal and dynamic testing as described above. The ITT and pyridostigmine bromide stimulating GH test revealed that 100% of the patients had GH deficiency; median basal GH was 0.05 ug/L . With the stimulation tests, the GH secretion curves were low and flat, of which the peak median GH values were 0.05 ug/L  and 0.05 ug/L  for ITT and pyridostigmine bromide stimulation tests, respectively; All of the patients were diagnosed with complete GH deficiency.The Gonadorelin stimulation LH test indicated that the patients had low and flat LH secretion curves, except for Patients No.15, 30, 47 and 51. The basic median LH level was 0.07 mIU/ml , and the peak median value of LH was 0.23 mIU/ml ; the median testosterone level in male patients was 0.36 ng/ml , and the median estradiol level in female patients was 36.7 pg/ml . The basal LH levels for Patients No.15, 30, 47 and 51 were 7.45 mIU/ml, 0.59 mIU/ml, 1.65 mIU/ml and 0.83 mIU/ml and the corresponding peak values after stimulation were 71.62 mIU/ml, 4.25 mIU/ml, 7.61 mIU/ml and 5.13 mIU/ml, respectively. Gonadotrophin deficiency occurred to 46 patients . When the status of the gonadotrophic axis was evaluated in boys older than 14 years and in girls older than 13 years, the prevalence of gonadotrophin deficiency reached to 95.8% (46/48).The mean basal ACTH level at 8 am was 3.77±1.88 pmol/L and median cortisol level at 8 am was 51.70 ng/ml . ACTH levels with the ITT gave low and flat curves, the mean peak value after stimulation was 4.31±2.47 pmol/L and the ratio of peak ACTH to basal ACTH was 1 . Secondary adrenal insufficiency was diagnosed in 81.8% (45/55) of the patients based on the 8 am cortisol levels and ACTH responses to ITT.P>0.05). Among the TSH higher group, thyroid ultrasound examination, and thyroid autoimmune antibodies were negative.Among the 55 patients, 42 patients (76.3%) were diagnosed with secondary hypothyroidism based on FT4 levels <10.4 pmol/L (the mean (±SD). TSH level in these patients was 5.11±4.10 uIU/ml and mean (±SD) FT4 level was 8.01±1.55 pmol/L). The FT4 levels in the remaining 13 patients were also near the lower limit of reference range, with mean (±SD) of 11.73±1.38 pmol/L (mean (±SD) TSH was 3.67±1.62 uIU/ml). In 15 patients, the TSH levels were >5.5 uIU/ml with a mean (±SD) of 8.86±4.36 uIU/ml . The FT4 levels were comparable between the higher TSH group and normal TSH group , 3(5.5%), 13(23.6%), 21(38.2%) and 17(30.9%), respectively. Therefore, 51 patients had more than 3 hypothalamic-pituitary hormonal abnormalities, accounting for 92.7% (51/55) of this group of PSIS patients.4, cortisol (F8 am) and LH peak in hypothyroidism group were much lower than that in non-hypothyroidism group while SDS of height and heights were higher (P<0.05); The ratio of upper body segment to lower body segment, bone age, FT4, basal LH and LH peak in hypoadrenalism group were lower than that in non-hypoadrenalism group, and the height and SDS of height were higher (P<0.05); In hypogonadism group, the age, ratio of male to female, breech delivery prevalence, height and bone age were much higher than that in non-hypogonadism group while basal GH, GH peak, cortisol (F8 am), testosterone (T), basal LH and LH peak were lower (P<0.05); The ratio of male to female and breech delivery prevalence were higher in hyperprolactinemia group while bone age, E2 and prolactin (PRL) were lower than that in normal prolactin group (P<0.05). There was no differences in terms of age, basal GH, peak GH, basal LH, peak LH, T, E2, PRL, basal ACTH, peak ACTH, 8 am cortisol, FT4 and TSH between the patients of short stature and normal stature patients (The FTpatients .P = 0.022), peak GH1 (P = 0.008), peak GH2 (P = 0.000), 8 am cortisol (P = 0.000) and borderline negatively correlated with FT4 (P = 0.061). While SDS height was negatively correlated with basal E2 (P = 0.030), peak PRL (P = 0.004), peak ACTH (P = 0.021), 8 am cortisol (P = 0.001), FT4 (P = 0.025) and borderline negatively correlated with T (P = 0.057).Height was negatively correlated with basal GH  height of 28±9 mm ; the pitThe mean (±SD) bone age was 12.28±2.93 years , which was lower than the actual age by a mean (±SD) of 7.26±5.37 years.PSIS was first reported by Fujisawa et al. in 1987 The exact prevalence of PSIS is uncertain, but a recently published report indicated the estimated incidence was approximately 0.5/1000,000 births In our study, Chinese patients with PSIS presented with sometimes different clinical characteristics compared to previous reports. We found a male predominance; the ratio of male to female was 6.9∶1 which is higher than 2.3∶1 reported in the literature Eighty-nine percent of the 55 patients presented for growth retardation and average heights were 144 cm. About 85% of PSIS patients had short stature. The average bone age was 12.28 years with a mean of 7.26 years younger than actual age. The delay of the bone age is much obvious than the 1.4 years in the literature Despite the uniformity of GH deficiency, patients had variable heights. The heights of 25% of our patient PSIS patients were within normal range, and 32.7% were taller than 155 cm and 12.7% were taller than 170 cm. The reason for this interesting phenomenon remains to be clarified. The difference between IGHD and PSIS was the latter suffered from multiple pituitary hormone deficiency as well as growth hormone. The height and growth of bone are influenced by many factors including growth hormone, thyroxin, cortisol, E2 and T. So, one possible explanation for the height of PSIS patients may be the complication of multiple hormones deficiencies. We further compared the heights and hormone levels in different hormone statuses and found the heights and SDS for heights in hypothyroidism group, hypoadrenalism group and hypogonadism group were higher than that in their control group. That indicated pituitary multiple hormone deficiencies other than growth hormone deficiency may contribute to the higher height in PSIS than IGHD. For instance, E2 and T are very important for the epiphyseal closure. Deficiency of these two hormones may result in the delay of bone age and difficulty in the closure of epiphysis. This could be supported further by our correlation analysis that multiple hormone correlated with height and SDS height and by the much larger differences between actual age and bone ages in PSIS than that in IGHD.Gonadotrophin deficiency is a common finding in patients with PSIS. However, its severity is variable, ranging from complete gonadotrophin deficiency to normogonadotropic amenorrhoea. We found that 9.1% of patients in this group presented for lack of puberty or poor development of secondary sex characteristics, and some patients have been diagnosed with idiopathic hypogonadotrophic hypogonadism. As a matter of fact, in our further investigation, all males with PSIS had absent pubertal development and only 2 female patients had partial pubertal development, and 95.8% of this group of PSIS patients over 14 years (boys) or 13 years (girls) exhibited poor secondary sexual characteristic development due to gonadotrophin deficiency, which was much higher than that reported in literature The frequency of multiple anterior pituitary deficiencies in PSIS varied in different series. In our series, we found 51/55 (92.7%) had three or more kinds of anterior pituitary dysfunction, which was much higher compared with reports in the literature. For example, Arrigo et al. Pituitary stalk lesions, which can interrupt normal dopaminergic inhibition of PRL, often result in hyperprolactinemia. Our study found the occurrence of hyperprolactinemia in PSIS was 36.4% and hypoprolactinemia was absent. While in a series of 27 PSIS subjects Anterior pituitary and posterior pituitary have different physiogenesis and blood supply In our study, PSIS was diagnosed primarily by the help of MRI, and its characteristic imaging was dysplasia of anterior pituitary, absence of pituitary stalk and ectopic posterior pituitary which was located near the optic chiasm and hypothalamus. All patients in this group had no visible pituitary stalk; no patient with thin pituitary stalk was found. The average height of anterior pituitary was 28 mm, which was similar to the report of others In the literature In general, the clinical features of our Chinese PSIS patients seem to be different from other reported patients in regarding to the higher degree of hypopituitarism and lower prevalence of midline defects. In addition, our patients were older at the time of case detection and the bone age was markedly delayed. We also had no cases of familial PSIS.From Jan. 2000 to Oct. 2011, we collected 55 cases of PSIS diagnosed among the 251 hospitalized hypopituitarism patients in our hospital, including 48 males and 7 females. The geographic distribution of patients included 17 from Northern China, 13 from Southern China, 11 from Eastern China and 14 from Western China. The diagnosis had been confirmed by MRI examination, dynamic endocrine evaluation of anterior pituitary function, and clinical features. The perinatal characteristics of these patients  and the positions of fetus at birth and whether or not anoxia occurred were recorded. No patients had relevant family history. This study has been approved by Ethics Committee of Chinese PLA General Hospital and due to the retrospective nature of the study, informed consent was waived. The subject of the photograph gave written informed consent, as outlined in the PLOS consent form, to publication of her photograph.Consanguineous parents, family history, perinatal histories , associated malformations , pubertal status, chronological age, bone age, height and so on were recorded. Height was expressed in standard deviation scores (SDS) for chronological age (CA). Short stature was classically defined by height less than −2 SDS for the CA. Microphallus was defined as a penis length less than or equal to 2.5 cm 4, T3, free T4 (FT4), and free FT3 were determined. The diagnosis of hypothyroidism was made if the basal serum FT4  was equal to or lower than 10.4 pmol/L.(a) Secretion of growth hormone: Thesecretory status of growth hormone (GH) was evaluated by pyridostigmine bromide test  and by insulin-induced hypoglycemia tolerance test (ITT) . Complete GH deficiency and partial GH deficiency were confirmed when the peak GH values in both tests were less than 10 ng/ml and 5 ng/ml respectively All the hormones in the study were analyzed by chemiluminescence immunoassay. ACTH and GH were detected using an Immulite 2000 Analyzer , while all others were measured with an ADVIA Centaur Analyzer . The differences between and within-batch were 2.22–4.69% and 1.58–4.59% for free thyroxine, 2.89–3.69% and 1.86–5.45% for 8 am cortisol, 2.3–6.2% and 1.4–4.7% for testosterone in males, 4.0–12.1% and 4.5–8.1% for estrogen in females, and 2.3–3.3% and 1.4–4.7% for prolactin, respectively. All blood samples were obtained in the morning and in the fasted state.Magnetic resonance imaging (MRI)  included dedicated sellar images with coronal and sagittal imaging after injection of Dimeglumine Gadopentetate. Bone age (BA) was determined using an X-ray image of the left hand and wrist according to Greulich and Pyle method.4, basal ACTH, peak ACTH, 8 am serum cortisol (F 8 am), testosterone (T), estradiol (E2), basal Luteinizing hormone (LH), peak LH, and prolactin (PRL). In addition, we analyzed the correlation between height or –SDS height and hormone status. Data were expressed as means ± standard deviations, percentage or median (interquartile range). Univariate comparisons between groups were performed by t-test for variables with normally distributed or Mann-Whitney U test and χ2 test when necessary. Correlations between height or SDS height and hormone secretion level were performed by Pearson correlation or Spearman correlation if necessary. P<0.05 was considered statistically significant. Statistical tests were performed using the SPSS17.0 statistical package.The data were analyzed based on the presence or absence of hypogonadism, hypoadrenalism, hypothyroidism or hyperprolactinemia. Pituitary-target gland functional status was also analyzed based on age (year), sex ratio, breech prevalence, height, -SDS height, ratio of upper to lower body segment (RUL), ratio of arm span to height (RAH), bone age, basal GH, peak GH, TSH, FT


To secure the best primary treatment of children a nationwide triage system has been instituted. The aim of this study was to evaluate the primary implementation in an Emergency Department(ED).Through a retrospective evaluation of medical records vital parameters and triage assessments made by an ED nurse were collected. Children younger than 13 years of age with no referral from a doctor were included (from October to December 2012) (n=127).A total of 81.9% (n=104) of the children were registered with triage colour indicating the level of urgency. This was done within a mean of 26.4 minutes from time of arrival. Children younger than 1 year old were significantly more likely not to be triaged compared to children older than 1 year old RR 2.78 (95% CI 1.31-5.93) (p=0.0249). Distribution of triage was; green (lowest level) 58.3%, yellow 24.4%, orange 16.5% and red (highest level) 0.9%. In 22.1% of the patients we identified a lower triage level than given with the vital parameters . The greatest risk of being under-triaged was found among children between 3-7 years (39.4%).A simple and clear triage system is of great importance in order to get a well functioning triage in an ED. We showed that special attention should be given to infants to secure proper triage and that children from 3-7 years of age is at the highest risk of being under-triaged.


Zinc deficiency perturbs the immune response and generates higher susceptibility of the human body to infections.The study’s primary outcome was the plasma concentration of zinc. The colorimetric method with Br-PAPS final point (CV% 0.98% - 4.64%) was used for the determination of the zinc level. Secondary outcomes were the prevalence of the acute infectious diseases in children and their relationship with plasma concentration of zinc. Data were processed using EPIINFO version 6.0.During 2009-2011, 98 healthy children, 0-3 years old, from Bihor county, Romania, were enrolled in the study. A total of 96 children recruited were available for analysis. In the study group (n=96) the mean plasma concentration of zinc was 15.33±1.49 μmol/L.Subjects with more than 3 episodes of acute respiratory infections/year had a statistically significant lower value of plasma concentration of zinc as compared to those who had less than 3 episodes/year .There are no significant differences between those who had an episode of acute diarrhea/year compared with more than 1 episode/year .Children with a history of parasitic infections had a mean plasma concentration of zinc similar to those without parasitic infections .In our study, the children aged 0-3 years showed no zinc deficiency. Smaller plasma concentrations of zinc were associated with more than 3 episodes of acute respiratory infections/year.


Cerebral microangiopathy is one of the most important complications in diabetes. It may interfere with cerebral vasomotor reactivity (VMR) which may lead to disability, stroke or even death. The aim of the present study was to determine and compare VMR changes in diabetic and non- diabetic patients.Fifty three diabetic and 51 non- diabetic patients  were recruited. Vasomotor reactivity was evaluated with Trans- Cranial Doppler (TCD) before and after CO2 inhalation.There were 69 (66.30%) males. The mean age was 41.53 ± 17.80 years. The general average of VMR was 5.79 ± 3.00%, the figures in diabetic and nondiabetic patients were 5.31 ± 2.60% and 6.62 ± 2.00%, respectively (p = 0.02). The average of flow velocity (FV) change was 42.47± 29.00 in diabetics and 53.34 ±16.70 in non- diabetic patients (p = 0.04).It is recommended that such non- invasive method is necessary for evaluation of cerebral vasculature in diabetic patients for better prevention. Transcranial Doppler (TCD) ultrasonography is a safe, noninvasive, and low-cost technique which neurologists utilize it for imaging the large intracranial vessels at the skull base.3Cerebral blood flow is regulated by changing in arterioles resistance,4689Diabetes is one of the well known risk factor for cerebrovascular accident (CVA).410108912TCD and VMR provide non-invasive and easy methods in predicting high risk patients for cerebrovascular accident,413The current study is conducted to determine the VMR changes in diabetic and nondiabetic patients.A cross-sectional study was conducted at a referral hospital affiliated to the Iran University of Medical Sciences (IUMS). Fifty-three patients with definite diagnosis of diabetes mellitus (NIDDM) who referred to endocrinology clinic were enrolled.Controls were 51 participants selected from those who visited the orthopedic minor trauma outpatient clinic of the same hospital or persons accompanying patients who admitted to the neurology ward. Selection of both cases and controls was done by an investigator (assistant of neurology). All participants (both patients and controls) underwent TCD by one neurologist who was unaware of their status.Non-cooperative cases and controls and those with a history of cerebrovascular diseases, coronary artery disease, hypertention, any vasculitis, anatomic abnormality of middle cerebral artery and poor window in TCD were excluded from the study.The Medical Ethics Committee of IUMS approved the study. Written informed consent as obtained from all cases and controls before participation in the study.This study was performed  to measure the cerebral blood flow velocity in the middle cerebral artery on both sides. End diastolic, peak systolic, and mean cerebral blood flow velocities were recorded automatically. After the finding of middle cerebral artery (MCA), the cerebrovascular CO2 reactivity measurement was performed as follows: the cerebral blood flow velocity was measured continuously and the participants first breathed room air through an anesthetic mask. Participants were then asked to inhale a mixture of 5% carbon dioxide in 95% oxygen for 2 minutes. The blood velocity of MCA is expected to increase after 20-30 seconds. The flow velocity (FV) indices were recorded if there was no increasing in the velocity.The cerebral VMR was determined according to indices as below:To compare the average of FV and VMR between the two groups independent t-test was utilized. A p value of < 0.05 was considered significant. All calculations were performed with the SPSS version 13.0 for Windows .All of 104 participants in this study were evaluated. There were 69 (66.30%) males and 35 females. The mean age (± SD) was 41.53 ± 17.80 years. The average of flow velocity (FV) changes in general was 47.80 ± 24.35 cm/s. In diabetic and non- diabetic patients the average FV were 42.47 ± 29.00 cm/s and 53.34 ± 16.70 cm/s, respectively (p = 0.04). The general average of VMR was 5.79 ± 3.00%. The figures in diabetic and nondiabetic patients were 5.31 ± 2.60% and 6.62 ± 2.00%, respectively (p = 0.02). The range of VMR in diabetic and nondiabetic cases was 1.71- 8.91% and 4.61- 8.66%, respectively. The average FV and VMR was compared between the two groups regarding age and it showed significant differences (p = 0.009). However, there was no statistical significance regarding sex (p = 0.06). The findings are summarized in tables  2Cerebrovascular reactivity is a hemodynamic parameter representing the increase in normal cerebral artery blood flow in response to a vasodilator stimulus such as hypercapnia.347812789The present results indicate that diabetes may decrease the brain blood flow reserve independent to age that may go along with an increasing risk for vascular events, although it still remains unknown if the duration of diabetes will enhance this deleterious effect. To elucidate the effect of sex, further studies with more patients may be needed.


Frequent blood transfusion in patients with beta thalassemia major can lead to iron overload especially in liver. Chronic iron overload could cause cirrhosis of the liver. Transfusion- transmitted hepatitis B and C also could develop cirrhosis in individuals.The present cross- sectional descriptive study is to assess hepatomegaly and liver enzymes in 100 patients with beta thalassemia major, ages between 2-18 years old. The study was carried out retrospectively. One hundred medical records have chosen from 400 samples of thalassemia major patients, who are under a regular care of the department of sarvar clinic. Out of these patients, 55% were male and 45% female. The mean age of thalassemia patients was 10.8± 4.4 years. The mean and S. D of hemoglobin, ferritin, deferoxamine dosage was 8.5 ± 1.5g/dl , 2183 ± 1528 ng , 30 ± 11.16 mg/kg, respectively. Forty six percent of them had hepatomegaly. The mean and S. D of AST and ALT were 95± 70 IU/L and 70 ±35U/L respectively. Splenectomy was performed on 44% of patient.Hepatomegaly is one of the most common findings in the thalassemic patient that induced with hemosiderosis and hepatitis.  Thalassemia is a problem of 60 countries with the highest prevalence in the Mediterranean region, parts of North and West Africa, the Middle East, the Indian subcontinent, southern Far East and southeastern Asia , 2. IranBeta-thalassemia represents a group of recessively inherited hemoglobin disorders first described by Cooley and Lee . The disTransfusion-associated viral hepatitis resulting in cirrhosis or portal hypertension also may be occurred , 12. In Italy 50% of thalassemic patients were estimated to have died before the age of 12 years . CornellAbdominal examination may reveal changes in the liver, gallbladder, and spleen. Hepatomegaly related to significant extramedullary hematopoiesis typically is observed. Patients who have received blood transfusions may have hepatomegaly or chronic hepatitis due to iron overload . .Frequent blood transfusion can lead to iron overload especially in liver. Liver has a large capacity to produce proteins, which bind the iron and store it in the form of ferritine and haemosiderin, therefore, it can produce sever iron overload. Chronic iron overload may lead to cirrhosis. Transfusion- transmitted hepatitis B and C also can develop to cirrhosis. Second leading cause of death in this patient after 15 years of old is cirrhosis. In these times most of them affected with cirrhosis, hepatitis B and C .. This study was aimed to assess the frequency of the hepatomegaly and liver enzymes in 100 patients with major beta thalassemia age between 2 – 18 years old, who attended to Sarvar clinic of Mashhad University of Medical ScienceThis work is a descriptive cross- sectional study. The study was carried out retrospectively. Medical records of all patients aged between 2- 18 years were used from 400 records of major beta thalassemia patients in Sarvar clinic, which were 100 cases. Frequency of the hepatomegaly, liver enzymes (ALT and AST), Hb, ferritin, deferoxamine dosage, age of splenectomy, and age of starting deferoxamine were extracted from the files. The normal range of AST, ALT was considered less than 35 IU/Lit. All patients had received blood transfusions since infancy. Liver enzymes levels were measured by commercial kits on the Hitachi 704 analyzer . Statistical analysisThe data was recorded in a questionnaire and analyzed using SPSS v.16. The patients were 55 (55%) male and 45 (45%) female. The mean age of thalassemic patients and age of starting the blood transfusion was 9±6 and 10/8± 4/4 months respectively. The mean and S. D of hemoglobin, ferritine, deferoxamine dosage was 8.5 ± 1.5g /dl , 2183 ± 1528 ng (269-6450) , 30 ± 11.16 mg /kg .Only 33 (33%) of patients maintained their hemoglobin levels >9.0 g/dl. and 37 (37%) Patients had ferritin levels >2,000 ng/ml. Forty six (46%) of them have hepatomegaly. Splenectomy was performed on 44(44%) of patient. The mean and S. D of AST and ALT were 95 +/- 70 IU/L, 70 +/- 35U/L respectively. Sixty children (60%) used daily acid folic, and 12(12 %) vit C. Analyzed data revealed that there is no significant difference between the mean of hemoglobin, ferritin, deferoxamine dosage, AST, ALT and hepatomegaly among men and women. There was a significant relation between age of starting transfusion and age of starting deferoxamine (r=0.31 p =0.002). There was a significant relation between level of hemoglobin and deferoxamine dosage (r=0.3 p =0.005).Hepatomegaly in patients with ages more than 10 years was reported in 34 cases (74%), but in less than 10 years was found in 12 cases (26%) .There is no relation between hepatomegaly and the level of ferritin, Hb, gender and splenectomy.There is a significant relation between hepatomegaly with splenomegaly , and also with usage of folic acid (0.046).The mean and S. D of hemoglobin was 8.5 ± 1.5g / dl. Yin and et al reported 44.6% of patients maintained their hemoglobin levels >9.0 g/dl . In thisThe mean and S. D of ferritine were 2183 ± 1528 (269-6450) ng. Yin reported the mean serum ferritin level 3,143 ng/ml . Li repoCunningham reported ferritin levels from 147 to 11 010 ng/mL . Mazza rMean serum ferritin in patient with weight more than 5 percentile was 2309+/-1284, and with weight less than 5 percentile was 3199+/-1545 . In patient with normal BMI, mean serum ferritin was 2679+/-1378, and it was 2596+/-1777 with low BMI. High serum ferritin levels during puberty cause delay of growth retardation and development in transfusion dependent thalassemia patients . The mean and S. D of ferritine in this research is similar to another research. Iron overload in patients with thalassemia is a common feature, which requires continuous chelation therapy and monitoring. Serum ferritin determination is widely accepted as a simple method for following iron load in patients with primary hemochromatosis. However, several reports on thalassemic patients emphasize that ferritinemia is not accurate. Direct measurement of iron in the liver (HIC) and magnetic resonance imaging (MRI) are more precise. A research on 33 thalassemic patients showed Ferritin levels ranged between 276 and 8031 ng/mL, and liver iron content ranged from 1.6 to 31.0 mg/g dry weight. Grade III or IV liver siderosis was recorded in 23/33 these patients, which they showed severe or very severe siderosis at MRI . SignifiThe study shows that serum ferritin levels significantly correlated with the true status of hemochromatosis in thalassemic patients . In presAll of the patients with beta thalassemia major must start blood transfusion before 2 years old. The mean and S. D of deferoxamine dosage was 30 ± 11.16 mg / kg. One research in Hong Kong reported deferoxamine dosage between 20 -50 mg / kg . Yin repForty six percent of our patients had hepatomegaly. In a study conducted by Berak etal showed that 50% of patient had hepatomegaly, 23.68% moderate splenomegaly, 25.79% sever splenomegaly . Severe The association between iron overload and pathology of the liver in transfusion-dependent patients with β thalassemia major has been extensively studied. Viral hepatitis is an important cause of the acute and chronic hepatitis، cirrhosis and hepatocellular carcinoma. Because of the frequent transfusions، thalassemic patients are at a greater risk of developing these problems . The presence of liver fibrosis in patients with beta-thalassemia major has been demonstrated to be an important negative prognostic factor. Identification of liver fibrosis in early stage would have great value. Previous histopathology study showed liver fibrosis including stage I and stage II by biopsies in 80% of the patients . In present study, the mean and S. D of AST and ALT were 95 +/- 70 IU/L and 70 +/- 35U/L, respectively. Similar study by Company et al in Kurdistan on 40 patients with beta thalassemia major showed that mean SGOT levels in hypothyroid and normal patients were 38.7 ± 14.8 U/L and 50 ± 27.8 U/L (p= 0.2) respectively. So thyroid dysfunction could not be correlated with liver function or plasma ferritin level . A research on 104 patients with beta thalassemia major showed a significant correlation between iron level as indicated by transferrin saturation or serum ferritin levels and SGOT, SGPT levels. Abnormal liver function represented by elevated levels of SGOT, SGPT and serum alkaline phosphatase, which was observed more frequently in patients with iron overload than in patients with a lower level of iron . A study in Pakistan showed that 47% of their patients had an increased alkaline phosphatase, which might be attributable to liver disease . Shams e A research on 99 patients with multiple transfusion in China showed the seropositive hepatitis C antibody patients had higher serum alanine aminotransferase, aspartate aminotransferase and ferritin concentrations  than the seronegative patients  . A study. Serum ferritine and LFT were elevated in most patients in spite of defferoxamine pump use. It seems reevaluation of the current protocol of the defferoxamine administration needed.Hepatomegaly is one of the most findings in thalassemic patient that induced with hemosiderosis, extra medullary hematopoiesis, transmitted hepatitis B and C and cirrhosis. So starting of deferoxamine in the perfect time could prevent hemosiderosis