Cytomegalovirus (CMV) reactivation is common in immunocompetent mechanically ventilated patients. Lungs are a frequent site of reactivation. CMV reactivation may be associated with higher mortality among these patients . Some stThe aim of this study was to assess the virulence of a staphylococcal pneumonia developed during CMV reactivation in a mouse model.4 PFU of murine CMV (MCMV) Smith strain. Seropositivity was confirmed by immunofluorescence in serum. MCMV was considered to be latent 4 months later. Reactivation was triggered by cecal ligature and puncture. Mice were considered to have a CMV reactivation 2 weeks later [8 CFU of Staphylococcus aureus to induce pneumonia. Twenty MCMV negative BALB/c mice were treated according to the same protocol, including cecal ligature and puncture (control group). Daily weight, signs of sepsis and spontaneous mortality were noted. After 15 days, surviving mice were euthanized. Blood and lung were collected for bacterial culture and histological examination. MCMV reactivation was assessed by RT-PCR in lungs and salivary glands. A second cohort of 20 mice were treated according to the same protocol (10 MCMV positive and 10 MCMV negative mice) but were sacrificed at day 2 and day 5 after pneumonia.The study was approved by our local ethic committee. Female BALB/c mice were used in all experiments. CMV primo-infection was obtained by intra-peritoneal inoculation of 2 x 105 vs. 2.4 × 102 CFU/ lung, p = 0.009), day 5  and day 15 .No mortality from staphylococcal pneumonia was observed in the control group whereas the mortality rate was of 10 % in the MCMV group (p = 0.15). Mean weight loss at day 1 was higher in MCMV mice than in control (1.5 g versus 0.9 g respectively). Macroscopic observation and bacteriological analysis of lungs showed staphylococcal abscesses in 4/20 (20%) mice in MCMV group as compared to 0/20 in control group at day 15. At day 5, 3/5 mice had lung abscesses in MCMV group as compared to 0/5 in control group. No lung abscesses were present at day 2 after pneumonia. Overall, 7/30 (23%) mice had lung staphylococcal abscesses in MCMV group as compared to 0% in control group . Mean lung bacterial count was significantly higher in MCMV mice as compared to control at day 2 (2.4 × 10In a mouse model, CMV reactivation leads to the switch from a non lethal to a lethal staphylococcal pneumonia, increases bacterial lung count and favors the occurrence of staphylococcal lung abscesses.


The 7-valent pneumococcal conjugate vaccine (PCV7) was added to the U.S. infant immunization schedule in the year 2000. By 2009, PCV7 introduction was associated with a 43% decline in all-cause pneumonia among U.S. children aged <2 years . In 2010Streptococcus pneumoniae is widely recognized as the primary bacterial pathogen causing community-acquired pneumonia in children  codes as a first-listed discharge diagnosis of pneumonia (480.xx–486.xx or 487.0) or by a first-listed discharge diagnosis of meningitis , septicemia  or empyema (510.xx) and a pneumonia code in another diagnosis field. Codes considered specific for pneumococcal infections were 481.xx, 038.2, 041.2, or 320.1 , PCV7 (January 2001–June 2009), and PCV13 (July 2010–December 2012) years. Two years were omitted from the analyses, calendar year 2000, when PCV7 was introduced, and July 2009–June 2010, which encompassed the atypical pandemic influenza period and the introduction of PCV13. Annualized monthly rates were modeled using negative binomial regression accounting for seasonal variation. Modelling rates over the three periods allowed estimation of linear trends in these three periods as well as comparison of rates in the PCV13 period to rates that would have been expected if trends in the PCV7 and pre-PCV7 periods, respectively, had not changed. Relative rates (RR) were used to compare study periods and calculate percentage changes from PCV7 years and pre-PCV years to PCV13 years ([1 − RR] × 100); annual rate differences between these periods were also calculated.The annual number of hospitalizations for pneumonia of Tennessee children aged <2 years were >2,000 in 1998 and 1999, before PCV7 introduction, and declined to <1,000 by 2010 through 2012, after introduction of PCV13 . Only ≤2Monthly annualized pneumonia hospitalization rates for Tennessee children aged <2 years showed the typical seasonal pattern with increases during winter . PneumonAnnual pneumonia hospitalization rates in Tennessee children aged <2 years decreased from 14.5 to 4.1 per 1,000 from pre-PCV years to PCV13 years. Compared with PCV7 years, the rate after introduction of PCV13 was 27% lower, indicating 1.5 fewer hospitalizations per 1,000 children. The total decline after the years before PCV7 introduction was 72%, or 10.5 fewer hospitalizations per 1,000 children annually . There wThe decrease in pneumonia rates described in this report suggests substantial direct benefits of PCV13 use in the early years after its introduction. All-cause pneumonia hospitalizations in children aged <2 years in Tennessee declined 27% after introduction of PCV13 in 2010 and a total of 72% after the introduction of PCV7 into the routine childhood immunization schedule in 2000. Among Tennessee children aged <2 years, these rate reductions meant >1,300 fewer pneumonia hospitalizations annually compared with the years before introduction of PCVs. During the full 12 years after PCVs were introduced, approximately 11,000 fewer children were hospitalized with pneumonia than would have been expected based on rates in the pre-vaccine years.Declines in pneumonia hospitalizations in children aged <2 years in Tennessee in the first 10 years after PCV7 introduction were similar to those previously reported for U.S. children overall. Pneumonia hospitalizations in U.S. children aged <2 years declined 43.2%  during 2000–2009  in 2000 was associated with a 43% decline in pneumonia hospitalizations in U.S. children aged <2 years by 2009.What is added by this report?Tennessee hospital discharge data documented a 27% decline in pneumonia hospitalizations in children aged <2 years by 2012, after the switch from PCV7 to 13-valent pneumococcal conjugate vaccine in 2010. The rate was estimated to be 4.1 per 1,000 population in 2012, a historically low rate that represents a 72% decline from the rate before PCV7 introduction in 2000. Tennessee children aged <2 years experienced about 1,300 fewer pneumonia hospitalizations annually in 2011 and 2012 than in the years before the use of pneumococcal conjugate vaccines (PCVs).What are the implications for public health practice?State health departments can use administrative data to evaluate the local impact of PCV vaccination programs. Decreases in pneumonia hospitalizations for children aged <2 years in Tennessee highlight the need to reassess current causes and appropriate management of childhood pneumonia.Although the pneumococcus was reported to be responsible for 20%–60% of community-acquired pneumonias before PCV introduction (


In data collected during the Third International Study on Mechanical Ventilation, we compared data from the Netherlands with a global cohort. We hypothesized that tidal volumes (Vt) were smaller and applied positive end-expiratory pressure (PEEP) was higher in the Netherlands, compared with the global cohort. We also compared use of non-invasive ventilation (NIV) and outcomes in both cohorts.A post-hoc analysis of a prospective observational study of patients receiving invasive mechanical ventilation was conducted in 494 ICUs around the world . The Dut2O versus 5.8 cmH2O (both P < 0.01). In the subgroup of patients with ARDS, Vt ml/kg was 7.6 and applied PEEP 8.8 cmH2O in the Netherlands versus 8.6 ml/kg (P = 0.41) and 8.3 cmH2O worldwide. In the Netherlands 7.1% of admitted patients received NIV as first mode of mechanical ventilation versus 15% in the global cohort. In both cohorts 18% of patients were hypercapnic at ICU admission. Fewer patients in the Dutch cohort showed an ICU-acquired pneumonia  and sepsis , but more patients evolved delirium .Vt was 7.6 ml/kg predicted bodyweight in the Dutch cohort versus 8.0 ml/kg and the median applied PEEP was 8 cmHAccording to our hypothesis, Vt was smaller and applied PEEP was higher in the Dutch cohort. Patients in both cohorts received larger Vt than recommended in prevention of ARDS . Hyperca


The KCL034 human embryonic stem cell line was derived from a normal healthy blastocyst donated for research. The ICM was isolated using laser microsurgery and plated on γ-irradiated human foreskin fibroblasts. Both the derivation and cell line propagation were performed in an animal product-free environment and under current Good Manufacturing Practice (cGMP) standards. Pluripotent state and differentiation potential were confirmed by in vitro assays. The line was also validated for sterility, specific and non-specific human pathogens. The donor couple signed the consent on May 26, 2009. HFEA Code of Practice that was in effect at the time of donor signature: Edition 7 — R.4. HFEA Code of Practice Edition 7 — R.4 was in effect: 02 Oct. 2008–30 Sep. 2009.We distribute Patient Information Sheet (PIS) and consent form to the in vitro fertilization (IVF) patients if they opted to donate to research embryos that were stored for 5 or 10 years. They mail signed consent back to us and that might be months after the PIS and consent were mailed to them. If in meantime new versions of PIS/consent are implemented, we do not send these to the patients or ask them to re-sign; the whole process is done with the version that was given them initially. The PIS/consent documents (FRO-V.6) were created on Dec. 18, 2008. HFEA Code of Practice that was in effect at the time of document creation: Edition 7 — R.4 (3.2Embryo culture and laser-assisted dissection of inner cell mass (ICM) were carried out as previously described in details . The cel3.3ICM plated on mitotically inactivated HFF were cultured as described . TE cell3.4Straws with the earliest frozen passage (p. 2–3) are thawed and new colonies are counted three days later. These colonies are then expanded up to passage 8, at which point cells were part frozen and part subjected to standard battery of tests .3.5Pluripotency was assessed using two different techniques: enzymatic activity assay [alkaline phosphatase (AP) assay] and immunostaining as described .3.6Spontaneous differentiation into three germ layers was assessed in vitro and in vivo as described . Targete3.7DNA was extracted from hESC cultures using a Chemagen DNA extraction robot according to the manufacturer's instructions. Amplification of polymorphic microsatellite markers was carried out as described . Allele 3.8aCGH was performed as described in details .3.9SNP array was performed as described in details .3.10HLA-A, -B and -DRB1 typing was performed with a PCR sequence-specific oligonucleotide probe  hybridization protocol at the certified Clinical Transplantation Laboratory, Guy's and St Thomas' NHS Foundation Trust and Serco Plc. (GSTS) Pathology  as described . HLA typ3.11http://www.sgs.com), in compliance with the principles of GMP as set out in Directive 2003/94/EC for medicinal products for human use (Validation for sterility and specific and non-specific human pathogens was performed as described . All valuman use  and 91/4uman use .Sterility testing was performed in accordance with the current requirements of the European Pharmacopoeia, Section 2.6.1 Sterility, U.S. Pharmacopeia, 71. Sterility Tests, and International Conference on Harmonisation Topic Q5D guidelines.Mycoplasma testing was performed in accordance with the current requirements of the European Pharmacopoeia, Section 2.6.7, Mycoplasmas.All PCR-based assays used were compliant with the current edition of the European Pharmacopoeia, 2.6.21, Nucleic Acid Amplification Techniques.4There are no competing financial interests in this study.


Although malaria is declining in many countries in Africa, malaria and anaemia remain frequent in children. This study was conducted to assess the relationship between malaria parasitaemia, intestinal worms, and anaemia, in children <5 years living in low transmission area in Senegal. A survey was carried out in 30 villages in the central part of Senegal. A two-level random cluster sampling technique was used to select study participant. Children <5 years were enrolled after informed consent. For each child, blood thick and smear tests were performed, haemoglobin concentration was measured with HemoCue, and stool samples were collected and examined using the Ritchie technique. A total of 736 children were recruited. Malaria parasite prevalence was 1.5% (0.7–2.6); anaemia was found in 53.4% (48.2–58.9), while intestinal parasites and stunting represented 26.2% (22.6–30.2) and 22% (18.6–25.5), respectively. In a logistic regression analysis, anaemia was significantly associated with malaria parasitaemia (aOR= 6.3 (1.5–53.5)) and stunting (aOR = 2 (1.2–3.1)); no association was found between intestinal parasites and anaemia. Malaria and anaemia remain closely associated even when malaria is declining. Scaling up antimalarial interventions may contribute to eliminate malaria and reduce the occurrence of anaemia among children. Malaria is a major public health problem in African region. According to the World Health Organization (WHO), in 2010, there were an estimated 149 to 274 million cases and 537,000 to 907,000 deaths worldwide [Anaemia also remains a major public health problem, not least in malaria endemic areas, where it is primarily seen in young children in areas with stable malaria, but also in adults in malaria unstable areas , 5. ReceIn tropical regions, there are multiple aetiologies to anaemia and intestinal parasites as well as malnutrition can play a major role in anaemia occurrence , particuThis study was aiming (i) to assess the prevalence of malaria parasitaemia, intestinal parasites (IP), anaemia, and malnutrition among children <5 years and (ii) to explore the relationship between malaria, intestinal parasites, malnutrition, and anaemia.The study was conducted prior to the implementation of an impact study evaluating the impact on malaria burden of a community-based malaria control strategy including effective case management (using RDT and ACT treatment) and IPTc at Lamarame in Senegal, where a demographic surveillance system recently has been established.The study was conducted at the Lamarame health post located in the Keur Socé, a rural community, at 17 Km from the city of Kaolack in central Senegal, and 200 Km from Dakar. The Lamarame health post is in the Ndoffane health district. It covers 34 villages located within a radius of 8 Km from the post, with a total population of about 10,000 inhabitants.Konate et al. unpublished data). Many programs aiming to reduce child health problems are being promoted in this area. These programs included two yearly vitamin A supplementation, and deworming with Mebendazole, in December and June of each year for children aged 1 to 5 years.Malaria is endemic in this area with a seasonal pattern of transmission peaking during the rainy season (July–November); entomological inoculation rates range from 9 to 12 infective bites/human/year , power at 90% (beta 10%), and being multiplied by 2 for an design effect.A code was given to every child after parents' informed consent. Each eligible child was examined by a physician prior to a biological assessment which included blood and stool samples. The mother was interviewed directly concerning the child's symptoms as well as well as sociodemographic characteristics using a standard questionnaire. Data obtained from physical examination and parents interview were assigned on a case report form (CRF).Z-score was used to denote underweight, while height for age Z-score was used as an indicator of stunting. The Z-scores were calculated based on the median values of the National Centre for Health Statistics (NCHS) reference population, United States.Children were weighed by a trained assistant, without their shoes, using Seca scales; height was measured to the nearest 0.1 cm using a calibrated scale and a sliding head piece. Weight-for-age μL using the following formula: numbered parasites ×8000/200 assuming a white blood cell count of 8000 cells per μL. Absence of malaria parasite in 200 high power ocular fields of the thick film was considered as negative.Blood samples were collected using finger prick blood. The first drop was used to prepare thick and thin smears for the diagnosis of malaria. Thick and thin smears were stained with Giemsa and read by a laboratory technician. Malaria was defined as any asexual parasitemia detected on a thick or thin blood smear. Parasitemia was numbered and expressed by number of trophozoites/The second drop of finger prick blood was drawn into a microcuvette for Hb determination (g/dL) using HemoCue machine (HemoCue Hb 301). Moderate and severe anaemia were defined as hb concentration below 11 g/dL and 8 g/dL, respectively.Fresh stools samples were collected into wide mouth screw-cap clean containers. Fecal samples were examined for the detection of intestinal parasite using the Ritchie technique. Intestinal parasite was recorded positive by the presence of helminthes and/or protozoans in the faces.Z-scores for weight-for-age (underweight) and height-for-age (stunting) were derived using Epinut Anthropometry. Children who had Z-scores below −2 standard deviation (SD) of the NCHS reference population median were considered to be malnourished.Data were entered in Excel software and analysed using STATA 10 software. To assess the nutritional status, data were transferred into Epi Info 3.04 d. The For descriptive data, percentage was used to assess the prevalence of each outcome. Proportions were compared using chi-square test or the Fisher exact test ; significance level of the different tests was 0.05 two-sided. A stepwise logistic regression was done for the determination of risk factors possibly associated with anaemia and under-nutrition. The validity of the final models was tested using the Hosmer-Lemeshow goodness of fit test.Seven hundred and thirty-six children  aged 6 months–5 years with a mean age of 2.5 ± 1.3 years participated in this study .Plasmodium falciparum was 1.5%. Moderate anaemia and severe anaemia were found in 53.4% and 12.5% of the children, respectively. A total of 193 (26.2%) children were found with at least one intestinal parasite. Parasites species were represented by Giardia intestinalis 15.6%, Entamoeba coli 10.9, Hymenolepis nana 1.9%, Ascaris lumbricoïdes 0.4%, Enterobius vermicularis 0.4%, and Trichuris trichiura 0.1%. Children with two intestinal parasites species represented 3,01% (22 children); one child  was coinfected with 3 intestinal parasites species. The overall prevalence of stunting and underweight was 22% and 16.3%, respectively ) (Anaemia (Hb < 11 g/dL) was significantly associated with age range from 12 to 23 months (aOR = 3.7 (1.7–7.9)), malaria parasite (aOR = 6.3 (1.5–53.5)), and birth-order higher than 3 (aOR = 1.6 (1.1–3.5)). Stunting was also significantly associated with anaemia in children under 5 years of age (aOR = 2 (1.2–3.1)). There was no statistically significant association between isolated intestinal parasites, such as 8–1.58)) .Giardia intestinalis, Entamoeba coli, Hymenolepis nana, Enterobius vermicularis, and Ascaris lumbricoïdes ), severe anaemia (OR 3.5 (1.9–6.4)), residence zone (OR 3.5 CI 95% (1.6–8.1)), and birth order >3 (OR 2.9 (1.3–6.6)). There was no statistically significant association between malaria and stunting (OR 1.2 (0.3–0.5)) as well as isolated intestinal parasites such ricoïdes .Factors associated with underweight were represented by moderate anaemia (aOR 1.7 (1.1–2.8)), severe anaemia (aOR 4.4 (2.3–8.4)), and age range from 24 to 35 months (aOR 8.9 (1.2–70.6)) .Malaria, anaemia, intestinal parasitic infections, and malnutrition remain serious public health problems especially in developing countries , 10. We P. falciparum infections (1.5%), while a high level of anaemia was observed. Despite the low prevalence of malaria parasitoemia, anaemia was more frequent in children with P. falciparum infections (OR 6.3). It, thus, appears that malaria is still closely associated with anaemia in this area, even in the context of the decline of malaria prevalence. A survey conducted in January 2009 (one year before) in a neighbouring area  showed a higher prevalence of malaria (7.2%) [National Malaria Control program annual report 2009). Scaling up antimalarial strategies such as early case detection and treatment, intermittent preventive treatment as well as long-lasting insecticide treated nets may even contribute to malaria elimination in this area and significantly reduce anaemia as a public health problem in rural Senegalese areas with similar disease patterns. Children with a birth order greater than three had an increased risk of developing anaemia. In other studies, high family size was associated with anaemia and undernutrition of children [Our study conducted in a malaria endemic area showed an unexpectedly low prevalence of a (7.2%) . These rchildren .Giardia intestinalis was the most frequent parasite (15.6%). The observed prevalence of Giardia in this study is consistent with those described in other countries [Giardia intestinalis on growth and health of children has been shown by several studies [Giardia intestinalis and anaemia, as well as malnutrition, this parasite is known for its ability to induce diarrhoea [Lamarame health post report-unpublished data). This can explain the low level of prevalence of helminthic infections. While ensuring an effective action against helminthic infections, mass administration of mebendazole does not act against protozoan infections. Albendazole can have an effective action against both protozoan and helminthic infections and can be a suitable molecule in mass deworming programs, particularly in areas where Giardia is frequent. Thus, replacing mebendazole by albendazole during a mass deworming programme could further reduce the frequency of helminthic infections as well as protozoan infections and, consequently, the occurrence of diarrheal disease and malabsorption syndrome.The study showed a high prevalence of intestinal parasite carriage (26.2%); ountries , 14. Theparasite .6%. The iarrhoea  and malaiarrhoea . Mass deMalnutrition remains frequent in children under 5 years with a prevalence of 22% of stunting and 16.3% of underweight. In 2005, the fourth demographic and population health survey found an average rate of stunting in rural areas of 20.6%, and the prevalence of underweight was 21.6% . Our datStudy Limitations. This study, conducted in a rural Senegalese area, has provided useful data for the control of some frequent tropical diseases. However, sociocultural and behavioural factors which may have a relationship with the occurrence of anaemia and/or malnutrition have not been evaluated in this study, in particular the intake of macro- and micronutrients and the patterns of weaning and supplementary feeding.Anaemia, intestinal parasites, and malnutrition are still frequent in the area of Lamarame, while malaria is declining in this part of Senegal. Despite the decrease of malaria in this area, malaria is still a contributing factor to anaemia in this area, due to the close association between malaria and anaemia. The combination of several antimalarial interventions may contribute to eliminating malaria in this region and reducing the occurrence of anaemia among children.


Neurally adjust ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. Physiological studies have demonstrated the benefit of NAVA on patient ventilator interactions and prevention of lung over inflation. However, clinical data are currently lacking.To compare NAVA and Pressure Support Ventilation (PSV) at the early phase of ventilator weaning in patients recovering from an acute respiratory failure.A multicenter randomized controlled trial of 128 intubated adults  was conducted in 11 intensive care units in France from April 2010 to June 2012. Patients were included as soon as they could tolerate PSV with a PS level ≤30 cmH2O, a PEEP ≤8 cmH2O and a FiO2 ≤50%. Patients were randomly assigned to NAVA (n = 62) or PSV (n = 66). The PS level in the PSV group and the NAVA level in the NAVA group were set to obtain a tidal volume of 6-8 ml/kg. The primary end point was the probability to remain in an assist mode during the entire first 48 hours. Secondary end points were duration of mechanical ventilation and 28 days mortality.67.2% (n = 45) in the NAVA group vs. 63.3% (n = 44) in the PSV group (p = 0.66).. The time spend in an assist mode during the first 48 hours was 47 [43-48] hours in the NAVA group vs. 47 [40-48] hours in the PSV group (p = 0.55). The asynchrony index was lower in the NAVA group (19.7% vs. 32.6%), so was the prevalence of dyspnea at day-1 (9% vs. 19%). The time to first extubation was 7 [2-10] days in the NAVA group vs. 7 [2-10] days in the PSV group (p = 0.78). The hospital mortality rate in the NAVA group was 14.5% (n = 9) vs. 21.2% (n = 14) in the PSV group (p = 0.2). NAVA and PSV were associated to similar oxygenation. NAVA was not associated with any adverse event.NAVA can be applied efficiently in a clinical setting and improves patient ventilator interaction. However, NAVA does not increase the probability to remain in an assisted mode nor it reduces hospital mortality.


Embryo implantation process is a complex phenomenon and depends on fetal and maternal factors interaction. Endometrial thickness is needed for successful implantation.We designed this study in order to assess adding human chorionic gonadotropin (HCG) to the conventional protocol in endometrial preparation in women with thin endometrium and a history of in vitro fertilization–embryo transfer (IVF-ET) failure. The non-randomized clinical trial study  was performed on 28 patients. Participants were women who were candidate for frozen-thawed (ET) and had two previous failed ET cycles because of thin endometrial. HCG was administrated  from the 8th day of cycle and when endometrial thickness reached at least 7mm HCG was discontinued and frozen thawed ET was done. Totally 28 patients were included. The mean ± SD age of participants was 30.39±4.7. The mean of endometrium thickness before and after HCG were 5.07±0.43 and 7.85±0.52, respectively p<0.001. Also, there were five clinically and chemically pregnant women.The findings of the study suggested that adding HCG to the conventional preparation method was an effective protocol and significantly improved endometrial thickness and pregnancy outcomes in women with previous embryo transfer failure because of thin endometrium. Embryo implantation process is a complex phenomenon -3 and deSecretion of human chorionic gonadotropin (HCG) is one of the first embryonic signals. Also, HCG is the embryo-endometrial relationship regulator . HCG conThis non-randomized clinical trial was approved by the Ethics Committee of Shaheed Sadoughi University of Medical Sciences. This study was performed from September 2013 to January 2014. Participants were selected among women who were candidate for frozen-thawed ET. All of patients had previous failed IVF cycle due to thin endometrium. The written consent was obtained from all of the participants. The inclusion criteria were: patients with at least 2 previous failed IVF cycle, thin endometrium (thickness <7 mm) despite conventional treatment in previous IVF cycles, pregnancy failure despite vaginal estrogen, sildenafil, vitamin E. Patients with intrauterine lesion such as sub mucosal leiomyoma, history of endometriosis, and thyroid disorders were excluded. .th day of cycle. The HCG vial (1500 IU) was diluted 10 times and one was injected every day. On the 12th-13th day trans-vaginal sonography was done. Endometrial thickness was measured by a blinded gynecologist. If endometrial thickness was proper, (at least 7mm) HCG stopped and after 24 hr progesterone 100 mg intramuscular was injected for 3 days. Finally, ET was performed. The mean number of ET was 2.12 ± 0.56. The pregnancy test (serum βHCG) was done two weeks after ET. Fetal heartbeat  was checked after two weeks.All the patients received 8 mg estradiol valerate from the second day of menstrual cycle and continued at least for seven days. HCG  was administrated  from the 8Clinical outcomes included: increase of endometrial thickness more than 7 mm, improvement of endometrial thickness >10% and >20%, βHCG titer more than 25 mIU/ml was considered as chemical pregnancy. Heart beats existence two weeks after chemical pregnancy was considered as clinical pregnancy.Statistical analysisAll statistical analysis was done by the SPSS software . The study sample size was calculated according to the “comparison the means” formula. The accepted differences before and after the trial was 0.5mm (α=0.05) and the study power was 0.9. The normal distribution of data was checked. Mean, standard deviations, minimum and maximum were calculated. Paired t-test was used to compare the endometrial thickness before and after trial. The statistical significances considered as 0.05.Totally, 28 patients were included. The mean age of the participants was 30.39 ± 4.70 years old. The youngest patient was 22 and the oldest was 41 years old. None of the patients had the history of chemical or clinical pregnancy. Before and after adding HCG, the mean scores of endometrial thickness in the frozen-thawed ET cycles were 5.07±0.43mm and 7.85±0.52 mm, respectively, which was significantly increased . AlthougThin endometrium is one of the major causes of assisted reproductive therapy failure -6. PropeSeveral biologic studies suggest that GCSF can be considered as an effective treatment protocol, which can improve IVF outcomes in women with thin endometrium and a history of repeated embryo implantation failure , 21, 26.The findings of this study suggested that adding HCG to the conventional preparation method was an effective protocol and significantly improved endometrial thickness and pregnancy outcomes in women with previous implantation failure due to thin endometrium.


Campylobacter infection is the most common cause of bacterial gastroenteritis in developing countries, including Madagascar. Reports of pathogenicity have not been consistent and repeated exposures over time seem to lead to the development of protective immunity in developing areas. We conducted this study to support evidence for these hypotheses by exploring the association between infection and age, the reoccurrence of infection and the pathogenicity of Campylobacter.We carried out a community-based longitudinal study of children under the age of 24 months in two rural villages in Moramanga, Madagascar. Children were visited twice a week and a stool specimen was collected in cases of diarrhoea. Stools specimens were collected bimonthly from all children enrolled, regardless of symptoms. Children were followed-up until the age of 36 months.st 2012, 508 children were included in the cohort. We detected 319 episodes of Campylobacter infection in total, and 43.3% (n = 220) of the children had at least one episode of intestinal Campylobacter infection. The rate of Campylobacter isolation from stool specimens was 9.3%. The annual incidence rate for symptomatic Campylobacter infection was 0.05 episodes/child. The probability of Campylobacter infection was highest between the ages of six and 23 months. Taking children under six months of age as the reference group, the age-specific odds ratio for the association was 5.0 (95% CI: 2.9-8.6) for children aged six to 11 months, 5.7 (95% CI: 3.3-10.0) for children aged 12 to 17 months and 3.3 (95% CI: 1.8-5.8) for children aged 18 to 23 months. A second episode of infection occurred 63 days after the first episode in children with primary infections, and after 137 days in children with multiple infections (p < 0.01). First episodes of Campylobacter infection were associated with diarrhoea .Between January 2010 and May 31Campylobacter may be acquired over time, following repeated exposures. However, Campylobacter infection prevention measures should be reinforced in the first year of life, as this age seems to be associated with the highest risk of diarrhoea during Campylobacter infection.Our findings suggest that protective immunity to  Escherichia coli in the aetiology of severe childhood diarrhoea in developing countries is well recognised: 373 days). The cohort of 508 children consisted of 259 girls and 249 boys . The characteristics of the cohort children were shown in Table Campylobacter. In total, 2965 (87%) of these samples were collected from children without diarrhoea during the cross-sectional survey, which was conducted at two-month intervals. The rate of Campylobacter isolation from all samples was 9.3% (319/3424): 8.9% (41/459) from diarrhoeic samples and 9.4% (278/2965) in non-diarrhoeic samples. Overall, 43.3% (220/508) of children had at least one Campylobacter infection; 16.4% (36/220) of the infected children had diarrhoea and 32.3% (71/220) had more than one episode of Campylobacter infection. Overall, 13.9% (71/508) of all children had more than one episode of infection. Identification to the species level was carried out for 271 of the 319 Campylobacter isolates: 190 (70.1%) were C. jejuni, 64 (23.6%) were C. coli and 17 (6.3%) belonged to other species. There were no statistically significant difference between the isolation rate of C. jejuni and C. coli from diarrhoeal and non-diarrhoeal samples . We found that children infected with C. jejuni were likely to have subsequent infection than those infected with C.coli : 4.7% (3/64) of children infected with C. coli and 21.6% (39/180) of those infected with C. jejuni had subsequent infection. Campylobacter isolation rates from diarrhoeic and non-diarrhoeic samples, by age group, are shown in Table Over the two 2-year study period, 3424 stool samples were tested for n = 32) of the children were already infected with Campylobacter: 6.2% (2/32) were symptomatic and the remaining (30/32) children were asymptomatic. The prevalence of Campylobacter infection, by age group, at the time of enrolment was 4.6% (17/369) for children under 12 months of age and 10.8% (15/139) for children aged 12 months or older. The frequency of Campylobacter infection at the time of enrolment differed significantly between age groups . The age-specific odds ratios for Campylobacter infection at the time of enrolment were 8.6 , 5.9 (95% CI:1.9-18.3), 5.7 (1.9-17.2) for the 6-11 month, 12-17 month and 18-23 month age groups, respectively.At the time of enrolment, 6.3%  for children aged six to 11 months and 5.7 (95% CI: 3.3-10) for those aged 12 to 17 months  of patients with diarrhoeal episodes due to fever and to 17.8% due to the presence of blood or mucus in the faeces (3.1% for blood and 14.8% for mucus in the faeces). Mild dehydration was observed in four episodes of diarrhoea.n = 273) of the children presented at least one episode of diarrhoea during the observation period. The highest incidence rates were obtained for children under the age of 12 months. The annual incidence was 0.8 episodes/ child (95% CI: 0.7-0.9 episodes/child) in children aged 0 to 11 months and 0.5 episodes/child (95% CI: 0-0.6 episodes/child) for children over the age of 12 months.We observed 475 diarrhoeal episodes with a median duration of 4.5 days (IQR: 5 days), resulting in an annual incidence rate of 0.7 episodes/child (95% CI: 0.7-0.8 episodes/child). We were able to collect stool samples for 96.6% (459/475) of all diarrhoeal episodes. Overall, 53.7% . Among the children with diarrhoea, 13.2% (36/273) excreted Campylobacter and 16.7% (6/36) received antimicrobial treatments. The frequency of symptomatic Campylobacter infections did not differ between age groups .The overall annual incidence of symptomatic Campylobacter was isolated from 201(39.6%) asymptomatic children. The mean age for asymptomatic Campylobacter infection was 14.7 months .Campylobacter primary infection and diarrhoea . In the birth cohort of 64 children, the odds ratio for shedding Campylobacter for the first time among children with diarrhoea was 16.1 (95% CI: 1.8-140.8), taking children without diarrhoea as the reference group.There was a statistically significant association between p < 0.01, log-rank test). Figure Infection recurred more rapidly in children with primary infections than in those with multiple infections: 25% of children with primary infections had their second infection episode 63 days after the first episode, whereas the second episode occurred after 317 days after the first episode in children with multiple infections (To our knowledge, this is the first cohort study on diarrhoea in children in Madagascar.Campylobacter infection in children in Moramanga, as we observed an age-related decrease in infection rates and the time to recurrence was shorter in children with primary infections than in those with multiple infections. Our data also suggest that the first Campylobacter infection was associated to diarrhoea.Our results provide an indication of the role of the immunity on the occurrence of Campylobacter in other studies[Campylobacter infection in early infancy may thus be reduced by the acquisition of passive immunity from placentally transferred antibodies from immune mothers[Campylobacter infections during the first six months of life had significantly fewer anti-flagellum antibodies at birth than those who did not have Campylobacter infections during this period[Campylobacter infection was already reported to be associated with poverty[Campylobacter transmission in environments where there may be a poor hygiene conditions.We found an association between age group and infection, as reported in other developing countries,15, with studies. The fir mothers. A previs period,22. BreaCampylobacter infection was pathogenic. An analysis performed in a subset of the cohort, in newborns enrolled during the first 28 days of life, corroborated this finding. Reports of the pathogenicity of Campylobacter in different studies from around the developing world have not been consistent[Campylobacter infection may depend on bacterial virulence and host susceptibility factors[Campylobacter may differ in pathogenicity. There may also be animal host-adapted genotypes that never or rarely cause diarrhoea in humans[Campylobacter, we still need to elucidate the mechanism by which Campylobacter causes diarrhoea in humans and its interaction with the human immune system.We conclude that the first nsistent,8,15. Th factors, and strn humans. DespiteCampylobacter infection are multifactorial. Repeated exposure is required for the generation of acquired immunity, but exposure to different strains of Campylobacter and overwhelming challenge may overcome immunity[Our data showed that species-specific immunity is less likely to occur, however it is difficult to conclude about species-specific resistance to reinfection as it is possible that there was a reinfection with the same species but with strains having different antigenic properties, thus immunity is not effective. Strain and serotype differences might have also an importance in protective immunity; immunity in human seems to be serotype-specific, neitherimmunity. In deveimmunity.Campylobacter isolation in our study area was 9.3% and the annual incidence of symptomatic infection was 0.05 episodes/child. The rate of isolation of Campylobacter was lower than that reported for Peruvian children[Campylobacter in 13.2% of children with diarrhoea; this proportion has been estimated at 15.9% in the Central African Republic[Campylobacter species in developing countries, due to their fastidious growth requirements and/or the relative insensitivity of culture techniques, may influence detection rates[The rate of children but highchildren. Howeverchildren, Mexicochildren and Egypchildren. We docuRepublic, 3.3% inRepublic and 0.8%Republic. These don rates. We do nIn this study, we followed up a small sample of children included before the age of 28 days. An epidemiological study on this birth cohort might provide a better assessment of the role of immunity in determining the occurrence of infection.We have not included in the logistic mixed model a random-effect that account for clustering through time. This could have an impact on our results. However, the individual random-effect might already account for this autocorrelation over time even if the time is not explicitly represented. Visits were made at regular intervals and we have not visited many children at very short intervals.Campylobacter infection in children in the rural areas of Befotsy and Ampitambe, like in the other parts of the developing world. The association between infection and diarrhoea during the first year of life, the effect of the quality housing and the hygiene practices on the occurrence of recurrent episodes highlight the need for greater awareness of diarrhoeal disease prevention measures in infants and the importance of controlling Campylobacter infection. Prioritising interventions, such as those that may improve hygiene-related behaviors and/or the development of vaccines for prevalent Campylobacter serotypes, might have an impact on diarrhoeal illnesses in the developing world. The Moramanga HDSS constitutes a potential research platform for Campylobacter infection studies and vaccine trials.This study suggests the role of prior immunity and repeated exposures on the occurrence of The authors have no competing interests to declare.RVR conceived and co-ordinated the study, performed the statistical analysis and drafted the manuscript; FR participated in the design of the study and carried out the biological analysis of stool samples; PS participated in the design of the study and was involved in revising the manuscript critically for important intellectual content; HCR performed the PCR analysis; AR performed the field study and participated in the coordination of the study; IMR performed the PCR analysis; RR participated in the design of the study and the collection of data; VR participated in the design of the study and was involved in revising the manuscript critically for important intellectual content. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/372/prepubUnivariate analysis of risk factors for Campylobacter infection, Moramanga, 2010-2012.Click here for file


Some adolescents may have sleep disorder at some point during adolescence. Determining the pattern and practice of sleep among adolescents could be useful to establish a lasting sleep hygiene program among adolescents. The objectives of this study are to describe sleep pattern and practice among adolescent in Nigerian secondary schools.Sleep habits were investigated using a random sampling of adolescents from secondary schools from February to April 2013. A self-administered questionnaire was developed based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria. Epworth Daytime Sleepiness Scale and Pittsburgh Sleep Quality Index (PSQI) were used.2 = 32.89, p= 0.57). Twenty six (5.9%)of the subjects reported difficulty falling asleep.A total of 443 subjects, comprising 263 (59.4%) females and 180 (40.6%) males completed the questionnaire. The mean duration of night sleep of the subjects during weekday was 7.84 (1.9) hours and 8.65 (2.07) hours during the weekend. 22.8% (101/443) had abnormal sleep onset latency (< 5 minutes and > 30 minutes). The gender of the subjects did not influence the sleep onset latency (χAdolescents have varying degrees of sleeping practice and hygiene. Sleep problem usually entails a sleep pattern that is unsatisfactory or cause of concern to the parent, child or physician. Children present to primary care physicians or pediatricians with mainly three types of sleep related problems-first group has disorders of initiating and maintaining sleep (dyssomnias); second category (hypersomnias) is characterized by excessive sleepiness and third section represents abnormal activity or behavior during sleep, also classified as parasomnias . The aveBehavioral sleep problems defined as sleep problems that do not have a physiological aetiology, but rather a behavioral are reported in between 20% - 40% of children and adolescents . These sThere exist a connection between socioeconomic class and sleep habits among adolescents, for instance Kahn et el  noted thThe study was conducted in secondary schools from the city of Enugu in South-Eastern Nigeria. Enugu is an urban area, It lies in the rainforest zone with two major seasons (Rainy and Dry) and a temperature of about 28-33oc. It has a population of about 500,000 people according to the National population census .This was a prospective study enrolling adolescent students aged 13-19 years in secondary schools located in south east Nigeria selected by random sampling. This study was carried out from February to April 2013 using convenient sampling method.Pittsburg Quality of Sleep Index (PQSI)[x (PQSI): It is aEpworth Daytime Sleepiness Scale (EDSS)[e (EDSS): It is ae (EDSS). ConfideEthical clearance for the study was sought from the Research and Ethical Committee of the University of Nigeria Teaching Hospital Ituku Ozalla. However since this work was done in a secondary school and not in the Hospital, we did not bother to finally procure the consent from the hospital. Verbal Consent was obtained from the adolescents, caretakers and teachers after they had been told that their participation was completely voluntary in nature, and that they could discontinue their involvement at any time. Anonymity and confidentiality of responses was also conveyed. We did not obtain a written consent because we wanted the work to be concluded within a short period, thus avoiding the protocols involved in getting a signed written consent. The procedure was accepted by the Head teacher and as such we did not document the procedures. Since the work was not executed in the hospital, the ethical committee did not bother to approve or reject the approval, as far as consent was granted by the head teacher. We did not obtain informed consent from the next of kin, caretakers, or guardians, since we believe that the head teacher has already granted us consent.All data were coded, entered, and then analyzed using the Statistical Package for Social Sciences program (SPSS), version 16. Descriptive results were expressed as frequency, percentage, and mean ± S.D. P-values < 0.05 were accepted as statistically significant. Pearson chi-square was used to test for significant relationships between categorical variables. Non-parametric Spearman Rank Order was used to test for correlation between continuous and ordinal variables. A difference in means between groups was carried out using student's t- test.A total of 443 subjects, comprising 263 (59.4%) females and 180 (40.6%) males completed the questionnaire. The mean age of subjects was 15.79 (1.40) years. The mean age for females was 15.75 (1.42) and that of males was 15.85 (1.34). The age of both sexes was well matched . Subjects socioeconomic distribution showed that 183 (41.3%), 144 (32.5%) and 116 (26.2%) belonged to the high, middle and low socioeconomic class respectively. There was no significant difference in the gender and socioeconomic class distribution of the subjects. 2 = 32.89, p= 0.57). The mean duration of night sleep of the subjects during weekday was 7.84 (1.9) hours and 8.65 (2.07) hours during the weekend. There was a significant difference in the mean duration of night sleep during the weekday and weekend . There was no significant difference in the mean duration of night sleep between the males and females either during the weekday or weekend (p=0.51 and 0.88 respectively). On nocturnal awakening frequency, the subjects reported as follows: 85.6% (380/443) had nocturnal awakening frequency of 1-2 times per night, 12.9% (57/443) had frequency of 3-4 times per night and 1.4% (6/443) had frequency of more than 4 times per night.Result of the sleep onset latency of the subjects showed that 59 (13.3%) had sleep onset latency of less than 5 minutes, 41.8% (185/443) had latency of 5-10 minutes, 35.4% (157) had latency of 11-30 minutes while 9.5% (42) had sleep onset latency of more than 30 minutes. This indicates that 22.8% (101/443) had abnormal sleep onset latency (< 5 minutes and > 30 minutes). The gender of the subjects did not influence the sleep onset latency  did sleep walk, 15.1% sleep talk, 7.6% grind their teeth (bruxism), 16.5% had restless leg syndrome while 26.4% act out their dreams. There was no correlation between unusual sleep behaviours and sleep latency or night awakening frequency. Twenty six (5.9%)of the subjects reported difficulty falling asleep while 2.0% and 2.9% reported restless sleep and morning headache respectively. Nine subjects (2.0%) did always experience uncomfortable sensation in their legs during sleep. About 6.6% did hallucinate while falling or awakening from sleep, 2.0% did report of libido/erectile dysfunction while sleeping while 3.8% reported feeling of panic on awakening from sleep. On the question of how likely one will fall asleep in some usual ways of life, 14.4% (64/443) did respond that they have high chance of falling asleep while sitting and reading. Also about 7.4% have a high chance of falling asleep while sitting and talking to someone. Twelve (2.7%) of the subjects admitted they have a high chance of sleeping while driving.Adolescents go to bed earlier on weekdays than on weekends, with a total night time sleep of 7.84 hours and 8.65 hours on weekdays and on weekends respectively. Ideally adolescents need 9 hours and 15 minutes of sleep, children need 10 hours and adults need 8 1/4 hours . This isIn keeping with findings in Western countries  and seveAbout a quarter of adolescents studied reported abnormal sleep latency. LaBerge  et al inMajority of the adolescent studied had nocturnal awakening frequency of 1-2 times per night. This is similar to that of Ravi  et al wh"Adolescents have varying degrees of sleeping practice and hygiene". We did not do sleep studies like Polysomnogram, Maintenance of Wakefulness Test due to lack of facility.


The KCL031 human embryonic stem cell line was derived from a normal healthy blastocyst donated for research. The ICM was isolated using laser microsurgery and plated on γ-irradiated human foreskin fibroblasts. Both the derivation and cell line propagation were performed in an animal product-free environment and under current Good Manufacturing Practice (cGMP) standards. Pluripotent state and differentiation potential were confirmed by in vitro and in vivo assays. Whole-genome single nucleotide polymorphism (SNP) array analysis detected loss at 8q24.23  . The gaiDonors were tested negative for Human Immunodeficiency Virus 1 (HIV1), Hepatitis B  and C Virus . We did not retest the line.We also generated research grade of KCL031 line that is adapted to feeder-free conditions.33.1http://www.hfea.gov.uk/2999.html). The donor couple signed the consent on Nov. 26, 2008. HFEA Code of Practice that was in effect at the time of donor signature: Edition 7 — R.4. HFEA Code of Practice Edition 7 — R.1 was in effect until Dec. 09, 2007, whereas 7 — R.4 was in effect: Oct. 02, 2008–Sep. 30, 2009.We distribute Patient Information Sheet (PIS) and consent form to the in vitro fertilization (IVF) patients if they opted to donate to research embryos that were stored for 5 or 10 years. They mail signed consent back to us and that might be months after the PIS and consent were mailed to them. If in meantime new versions of PIS/consent are implemented, we do not send these to the patients or ask them to re-sign; the whole process is done with the version that was given them initially. The PIS/consent documents (FRO-V.5) were created on Aug. 10, 2007. HFEA Code of Practice that was in effect at the time of document creation: Edition 7 — R.1 (3.2Embryo culture and laser-assisted dissection of inner cell mass (ICM) were carried out as previously described in details . The cel3.3ICM plated on mitotically inactivated HFF were cultured as described . TE cell3.4Straws with the earliest frozen passage (p.2–3) are thawed and new colonies are counted three days later. These colonies are then expanded up to passage 8, at which point cells were part frozen and part subjected to standard battery of tests .3.5Pluripotency in vitro was assessed using two different techniques: enzymatic activity assay [alkaline phosphatase (AP) assay] and immunostaining as described .3.6Spontaneous differentiation into three germ layers was assessed in vitro and in vivo as described . Targete3.7DNA was extracted from hESC cultures using a Chemagen DNA extraction robot according to the manufacturer's instructions. Amplification of polymorphic microsatellite markers was carried out as described . Allele 3.8aCGH was performed as described in details .3.9SNP array was performed as described in details .3.10HLA-A, -B and -DRB1 typing was performed with a PCR sequence-specific oligonucleotide probe  hybridization protocol at the certified Clinical Transplantation Laboratory, Guy's and St Thomas' NHS Foundation Trust and Serco Plc. (GSTS) Pathology  as described . HLA typ4There are no competing financial interests in this study.


We also observed no significant difference in auditory thresholds among smoker subgroups based on smoking frequency. In contrast, subjects smoked for longer duration (>5 years) showed higher level of auditory threshold (62.16±19.87 dB) at 12 kHz frequency compared with that (41.52±19.21 dB) of the subjects smoked for 1-5 years and the difference in auditory thresholds was statistically significant (p<0.0002). In this study, the Brinkman Index (BI) of smokers was from 6 to 440 and the adjusted odds ratio showed a positive correlation between hearing loss and smoking when adjusted for age and body mass index (BMI). In addition, age, but not BMI, also played positive role on hearing impairment at all frequencies. Thus, these findings suggested that cigarette smoking affects hearing level at all the frequencies tested but most significantly at extra higher frequencies.Lifestyle including smoking, noise exposure with MP3 player and drinking alcohol are considered as risk factors for affecting hearing synergistically. However, little is known about the association of cigarette smoking with hearing impairment among subjects who carry a lifestyle without using MP3 player and drinking alcohol. We showed here the influence of smoking on hearing among Bangladeshi subjects who maintain a lifestyle devoid of using MP3 player and drinking alcohol. A total of 184 subjects  were included considering their duration and frequency of smoking for conducting this study. The mean hearing thresholds of non-smoker subjects at 1, 4, 8 and 12 kHz frequencies were 5.63±2.10, 8.56±5.75, 21.06±11.06, 40.79±20.36 decibel (dB), respectively and that of the smokers were 7±3.8, 13.27±8.4, 30.66±12.50 and 56.88±21.58 dB, respectively. The hearing thresholds of the smokers at 4, 8 and 12 kHz frequencies were significantly ( Hearing is one of the most important tools of social communication. Hearing is known to be deteriorated gradually during the ageing process . In addiOn the other hand, smoking cigarettes is considered as a potential risk factor for the most life-threatening chronic diseases including cancers , cardiovascular and respiratory diseases , 16. In 2). All the experiments were undertaken considering the ethical issues and the study was approved by the Faculty of Biological Science, University of Dhaka (Ref. no. 5509/Bio.Sc). A survey was performed using a self-reporting questionnaire on smoking habit including duration of smoking, frequency of cigarette smoking/day, age, previous history of disease, weight and height of the participants.The study was conducted among 184 male subjects aged between 18–60 years who agreed in written to participate in audiometric testing. In this study, we did not include those subjects who had a habit of drinking alcohol and using portable music player with earphones. We also excluded those participants who had a previous history of ear diseases and suffered from illness at the time of survey. In addition, no subject was included in this study from other ethnic group or race. The body mass index (BMI) was calculated by using the formula: Weight in kg/ method. The descriptive statistics were also presented in the result. For each characteristics of the subjects, p-value and odds ratio were measured. For further confirmation, binary logistic regression analysis was performed to determine adjusted odds ratio and 95% confidence interval (CI). The regression analysis made use of the different predictor variables in the numerical form. Hearing level was taken as dependent variable, and smoking habit, age and BMI were considered as independent variables. The significance of the results was set at p < 0.05.Data were statistically analyzed using SPSS program version 22 software . As the data did not show normal distribution, the difference between each group was analyzed using Pearson’s χ2, respectively. The subjects were further categorized as underweight, normal weight and overweight based on their BMI <18.5, 18.5–25 and >25 kg/m2, respectively. The number of subjects under normal weight of smokers and nonsmokers were 63  and 62 , respectively  were smokers and 94 (51.08%) were non-smokers. Of the smokers (n = 90), 49 (54.4%) were aged ≤40 years and the rest 41 (45.6%) were aged >40 years . The meaectively , denotinp = 0.0001) higher than non-smokers at 8 and 12 kHz frequencies. The differences which might be attributed to smoking that smoking with BI≤440 caused impairment of hearing level at all the frequencies and that the hearing impairment was most evident at the higher frequency (12 kHz). Since the mean ± S.D of BI in this experiment was 129.25 ± 124.80, smoking group (n = 90) with an average BI of ~130 might cause hearing impairment at all frequencies compared to non-smokers.In case of control (non-smoker) subjects (n = 94), the average auditory thresholds observed at 1, 4, 8 and 12 kHz frequencies were 5.63±2.10, 8.56±5.75, 21.06±11.06, 40.79±20.36 dB, respectively . When thp<0.05) in hearing impairment at almost all of the higher frequencies. However, the difference was not found significant (p = 0.06) between smoker and nonsmoker older than 40 years at the extra higher frequency (12 kHz). As hearing loss was more profound for the older age group  at that frequency, significant difference probably was not obtained.The prevalence of hearing impairment was found higher among smokers of both age groups (≤40 and >40 years) compared with those of the nonsmokers at all the frequencies tested . At 1, 4p > 0.05; We divided the smokers into 3 subgroups depending on their frequency of smoking per day  to examip = 0.005). However, at lower frequencies such as 1, 4 and 8 kHz, the results were not found significant . As the auditory threshold (62.16±19.87 dB) for smokers who smoked for more than 5 years exceeded far from the normal value of 40 dB at 12 kHz extra high frequency, it might be concluded that smoking cigarettes for long time chronically affect hearing levels.The effect of smoking duration on hearing level was also examined. Smokers were divided into two subgroups : smokingAssociation of hearing loss with smoking was further examined by logistic regression. The hearing loss (>40 dB for 12 and 8 kHz frequencies and >20 dB for 4 and 1 kHz frequencies) was taken as dependent variable and smoking habit, age, BMI of the participants were considered as independent variables. The independent variables were categorized considering nonsmoker, age ≤40 years and BMI  as reference group. Smoking and age were found to affect the hearing level more profoundly than the control groups after adjusting these factors . The resThis study showed that smoking cigarettes significantly increased the risk of hearing impairment especially at higher frequencies. Among the smokers, 35% found to be smoked 1–10, 45% smoked 11–20 and 10% smoked more than 20 cigarettes daily. As compared with the non-smoker group, the smoker group was found at higher risk of developing hearing loss due to showing higher hearing thresholds at various frequencies tested. According to our results, the smokers with higher hearing thresholds at 4, 8 and 12 kHz might be more vulnerable for developing hearing loss due to showing significant difference in hearing levels in those frequencies. Our study correlates with some previous reports showing smoking mediated hearing loss at extra-high frequencies , 21, 28.p>0.05; The association between smoking or alcohol consumption/exposure to occupational noise/use of MP3 player and hearing loss have been shown in earlier studies . Ohgami Some previous studies have been carried out to distinguish the synergistic effect on hearing impairment between smoking and aging or other related factors , 19, 29.There are some limitations associated with the present study. The study was conducted using a self-reporting questionnaire on smoking habit, age and previous disease history of the participants. Data obtained through self-reporting were adopted directly without testing their authenticity by any other means. This limitation was probably minimized by guaranteeing the participants that their answers would be kept confidential. Apart from their smoking habit, the subjects with an earlier history of diseases were excluded and therefore the influence of this important risk factor on hearing could not be analyzed due to incompleteness of the data. No female subjects were included in this study mainly because female smokers are relatively rare in urban areas of Bangladesh. For this reason, we could not compare the effect of smoking on hearing level between male and female smokers. Nonetheless, based on the findings of the current study these limitations do not prevent to conclude that smoking impaired hearing level on the subjects with a wider range of age group (18–60 years).Although the exact mechanism by which smoking affects the auditory organ is still unclear, several studies pointed out some mechanisms including direct ototoxicity of nicotine, cochlear ischemia due to increased levels of carboxyhemoglobin, and smoking-mediated increased blood viscosity –33. TherS1 FigFrequency distributions (means ± SD) of tone burst sound (1–12 kHz) output by (A) PTA system and (B) iPod are presented. Both devices used earphone-type headphone (Panasonic RP-HJE150). The PTA system consists of PR2.1 Enhanced Real Time Processor, PA5 Programmable Attenuator and HB7 Headphone driver . Sound levels from an earphone in a soundproof room were measured by a noise level meter  for 30 seconds and calculated as average of three repeated measurements. Background levels measured in a soundproof room without sound-generating devices were subtracted from sound levels from the earphone. Whole sound levels of (A) PTA and (B) iPod measured by the noise level meter without FFT analyzing software were almost the same (70 dB SPL).(TIF)Click here for additional data file.S2 FigHearing levels (1–12 kHz) of eight subjects (21 years old) measured by PTA (closed square) and iPod (open diamond) are presented.(TIF)Click here for additional data file.


Human papillomavirus (HPV) is a causative agent in oropharyngeal squamous cell carcinoma. The natural history of oral HPV in HIV-positive men who have sex with men (MSM) is unclear.Detection of oral human papillomavirus in 173 HIV-positive MSM using oral rinse samples 3 years apart was investigated. HPV DNA was detected by polymerase chain reaction, and genotyped by Roche Linear Array.Of 173 men tested in 2010, 30 had at least one HPV genotype , 15 at least one hr-HPV  and 8 had HPV 16  detected. In 2013, 33 had at least one HPV genotype , 20 had at least one hr-HPV  and 7 had HPV 16  detected. Of 30 men at baseline (2010) with any HPV detected, 14  had at least one persistent genotype. Of the 15 men in 2010 with high risk (hr-) HPV, 6 men  had at least one persistent hr-HPV genotype. The incidence rate of detection of at least one new HPV genotype was 4.8 per 100 person years (95% CI: 3.1–7.0), of at least one hr-HPV genotype was 3.2 per 100 person years (95% CI: 1.8–5.1) and of HPV 16 was 0.8 per 100 person years (95% CI: 0.2–2.0). The clearance rate was 14.9 per 100 person years (95% CI: 8.2–24.2) for any HPV, 18.2 per 100 person years (95% CI: 8.2–32.7) for hr-HPV and 17.4 per 100 person years (95% CI: 5.0–38.8) for HPV-16. Persistent HPV detection was associated with duration of HIV , 95% CI: 1.00–1.26) and tonsillectomy .The same oral HPV genotype was detected again after 3 years in nearly half of HIV-positive men who have sex with men. Human papillomavirus (HPV) causes a significant proportion of oropharyngeal cancers, most commonly in the lingual and palatine tonsils or base of tongue. There has been an increase in oropharyngeal cancer incidence in younger individuals and the proportion of these tumours associated with HPV continues to rise Understanding the natural history of oral HPV is important for determining the significance of HPV detection. The prevalence of oral HPV detection is higher in HIV positive than in HIV negative people We previously measured oral HPV detection among HIV positive men who have sex with men (MSM) th Dec 2012 and 6th Aug 2013, they were invited to participate in this follow up study and written informed consent was sought. At the time of their clinic visit, participants provided an oral rinse sample (ORS) that involved swishing and gargling 20 mL of sterile saline in the oral cavity for 10–20 seconds and then spitting into a specimen cup. This was the same method used for collection of samples in 2010. A questionnaire was completed by participants that asked about basic demographics, oral hygiene habits, smoking status and sexual practices  HIV clinic who participated in an oral HPV sampling and prevalence study in 2010 ractices .g and subsequently resuspended in 800 µl of PBS. An aliquot of 200 µl was extracted by the automated MagNA Pure 96 isolation and purification system (Roche Molecular Systems) using DNA and Viral NA Small Volume isolation kit. Following nucleic acid isolation, all samples were initially assessed for DNA adequacy with a quantitative PCR for a 260 bp fragment of the human beta-globin gene using 10 pmol each of β-globin primers GH20 [5′-GAAGAGCCAAGGACAGGTAC-3′] and PCO4 [5′-CAACTTCATCCACGTTCACC-3′] and 2 pmol of adapted probe PCO3 [5′-6-FAM-ACACAACTGTGTTCACTAGC-TAM-3′] ORS samples were centrifuged for 15 minutes at 4,600 Stata Statistical Software: Release 13. College Station, TX). For each participant, data from both the 2010 study and the current study were analysed and compared. Proportions of individuals infected with HPV types were calculated for type-specific persistence and the detection of new HPV genotypes. Persistent HPV was defined as detection of at least one of the same HPV genotype at both study timepoints with a mean difference of 2.9 years. A newly acquired detection (incident detection) was defined in this study as at least one new HPV genotype in 2013 in a person who was negative for that HPV genotype in 2010. A cleared infection was defined as the lack of detection in 2013 of at least one specific HPV genotype that was detected in 2010. From this, incidence and clearance rates of at least one HPV type per 100 person years and 95% confidence intervals were calculated for individuals. Prevalence, persistence and incidence rates for specific HPV genotypes were also calculated.Statistical analyses were performed using STATA  and sexual behaviors . After including all variables with p value <0.1, backward stepwise logistic regression provided a final model for HPV detection. Statistical significance was set as probability values of less than 0.05. This research was approved by the Alfred Health Human Ethics Committee (Project 384/12).Of 249 HIV-positive MSM from the 2010 study, 210 (84%) attended the centre during the 8 months recruitment period. Thirty-seven men declined to participate  and 173 (69%) men were recruited. The mean age of participants was 52 years (SD ±14). The average duration of HIV (from first positive Western blot test) was 11.8 years, the mean current CD4 count was 679 cells/µl and 91% of participants had a suppressed viral load (<20 copies/mL). Ninety-four % were currently on antiretrovirals and 32% were current smokers.Overall, beta globin, a measure of sample adequacy, was positive in 173 (100%) samples for ORS. The cell number estimation performed by comparison of crossing points from the real-time beta-globin PCR with known standards showed no difference between cell numbers obtained between those that were HPV positive and negative samples.Of the 173 men tested in 2013, 33 had at least one HPV genotype , 20 had at least one hr-HPV  and 7 had HPV 16  detected. In 2010, 30 had at least one HPV genotype , 15 at least one hr-HPV  and 8 had HPV 16  detected.Twenty four men  had at least one incident HPV genotype in 2013. Fourteen men  had at least one incident hr-HPV. Of these, 4 had new HPV 16 detections. The incidence rate of detection of at least one new HPV genotype was 4.8 per 100 person years (95% CI: 3.1–7.0), of at least one hr-HPV genotype was 3.2 per 100 person years (95% CI: 1.8–5.1) and of HPV 16 was 0.8 per 100 person years (95% CI: 0.2–2.0).The prevalence of specific genotypes is summarized in To evaluate HPV persistence, we compared the 2010 HPV profiles of HPV-positive men with their 2013 HPV profile. Of 30 men in 2010 with any HPV genotype detected, 14  had at least one persistent genotype. Of the 15 men in 2010 with hr-HPV detection, 6 men  had at least one persistent hr-HPV genotype. Of the 8 men in 2010 with HPV16 detection, 4 men  had persistent HPV16 detection. The clearance rate was 14.9 per 100 person years (95% CI: 8.2–24.2) for any HPV, 18.2 per 100 person years (95% CI: 8.2–32.7) for hr-HPV and 17.4 per 100 person years (95% CI: 5.0–38.8) for HPV 16.There were 52 HPV genotype detections in 30 individuals at baseline (2010). Sixteen  genotypes were identified again in the same individuals in 2013 . Of 19 hWe found no sexual behavior variables were statistically associated with persistent oral HPV (any or high risk types). Longer duration of HIV , 95% CI: 1.00–1.26) and past tonsillectomy  were the only two demographic factors associated with persistent HPV detection compared to men with non-persistent (any) HPV. These same factors were not statistically significant for hr-HPV, most likely due to the small sample numbers of hr-HPV in our sample. We did not find any statistically significant relationship between current CD4 count and HPV prevalence (p = 0.88) or persistence (p = 0.48).This study extends the body of knowledge of the natural history of oral HPV in HIV-positive MSM by demonstrating that 43% of men had at least one of the same oral HPV genotypes and that 40% of men had a least one high-risk HPV genotype detected again three years later. In a comparable study of HIV-positive MSM, it was found that 52% of any oral HPV genotype persisted for a median of 2 years, however the study did not provide any clearance rate for hr-HPV We found that at either time point, about 1 in 10 men had at least one hr-HPV detected and of particular concern is that of 8 HPV16 genotypes detected in 2010, 4 were still present in the same men three years later. Persistent infection is a risk factor for malignant transformation in genital epithelium and even though hr-HPV genotypes  are consistently detected in the majority of oropharyngeal squamous cell cancers The detection rates of 19% of participants with any oral HPV, 12% with hr-HPV, and 4% with HPV16 in a HIV-positive population stands in contrast to the US general population prevalence of 7% for any oral HPV, 4% for hr-HPV and 1% for HPV 16 persistent HPV. This may suggest that the underlying host immunity may be of greater importance than sexual behavioral factors for persistent oral HPV. The exact mechanism of this interaction between the duration of HIV and persistent oral HPV has been largely uninvestigated and warrants further research.Whilst there are other published studies evaluating sexual behaviors with detection of any oral HPV Increased association of tonsillectomy with persistent HPV detection has not been reported previously. Tonsils are an important secondary lymphoid organ in the immune system but tonsillectomy has not been shown to significantly impact humoral immune status in a HIV-negative population Due to the limitations of small numbers of persistent HPV and issues around detecting true persistence in previous studies and this study, it remains unclear whether there are additional factors that may increase the likelihood of persistence of HPV. A larger study to identify these factors would help stratify those at increased risk for persistent hr-HPV and theoretically those at higher risk for oropharyngeal cancer.Our study has a number of limitations that need to be considered. Firstly although we used the same method for oral sampling that others have used Nearly half of oral HPV genotypes, detected in HIV-positive men who have sex with men, were detected again 3 years later. Persistent HPV detection was associated with duration of HIV infection and tonsillectomy.Appendix S1Questionnaire. Written questionnaire completed by participants.(DOC)Click here for additional data file.


Many recent studies have shown the superior diagnostic accuracy of specific IgE (sIgE) to Ara h 2 compared to sIgE to peanut extract in diagnosing peanut allergy. The aim of this study was to analyze the association between severity and sensitization levels .Peanut allergic adults (n=94) and children (n=100) with a suspected peanut allergy were included. sIgE levels were measured by ImmunoCAP . In all subjects the adapted Mueller score was used with one additional category for no symptoms (0-5): 0; no symptoms/peanut tolerant, 1; oral allergy symptoms, 2; cutaneous/mucosal symptoms, 3; gastrointestinal symptoms, 4; respiratory symptoms, 5; cardiovascular symptoms. A severe reaction was defined as a Mueller score of 4 or 5. Univariate and multivariate logistic regression analysis was used to calculate odds ratio’s.Children had significantly higher Mueller scores than adults (P=0.003) and were therefore analyzed separately. In children 12 patients had a severe allergy, in adults 15 patients. In the pediatric population, none of the predictors was significantly associated with a severe peanut allergy, since the 95% CI of the OR of all predictors included the value 1. In the adult population, sIgE to Ara h 2  and sIgE to peanut extract  were significantly associated with a severe peanut allergy. A multivariable logistic regression analysis was not possible due to the low number of severely allergic patients. The AUC values of sIgE to Ara h 2 and sIgE to peanut extract in the adult population were 0.81 (95% CI 0.69-0.93) and 0.70 (95% CI 0.54-0.86), respectively (compared to 0.77 (0.64-0.89) and 0.69 (0.53-0.85) in the pediatric population).In children no predictor was significantly associated with severity of peanut allergy. In adults, specific IgE to Ara h 2 was a better predictor for severe peanut allergy than sIgE to peanut extract, but was still suboptimal for this purpose.


Solanum lycopersicum (123 accessions) and S. lycopersicum var cerasiforme (51 accessions) to detect significantly associated loci controlling the variation of main sugars and organic acids. The accessions were genotyped with 182 SSRs spreading over the tomato genome. Association mapping was conducted on the main sugars and organic acids detected by gas chromatography-mass spectrometer (GC-MS) over 2 years using the mixed linear model (MLM). We detected a total of 58 significantly associated loci (P < 0.001) for the 17 sugars and organic acids, including fructose, glucose, sucrose, citric acid, malic acid. These results not only co-localized with several reported QTLs, including fru9.1/PV, suc9.1/PV, ca2.1/HS, ca3.1/PV, ca4.1/PV, and ca8.1/PV, but also provided a list of candidate significantly associated loci to be functionally validated. These significantly associated loci could be used for deciphering the genetic architecture of tomato fruit sugars and organic acids and for tomato quality breeding.Association mapping has been widely used to map the significant associated loci responsible for natural variation in complex traits and are valuable for crop improvement. Sugars and organic acids are the most important metabolites in tomato fruits. We used a collection of 174 tomato accessions composed of  Sugars and organic acids are the key components impacting tomato quality and customer preferences. They account for over 60% of the dry matter, and contribute to soluble solid content (SSC) and also are essential to the flavor intensity  or association mapping have been widely used in identifying candidate QTLs/genes that are related to various agronomically important traits and to uncover the genetic architecture that controls these traits  and 51 large-fruit cultivars  with an electron ionization source. One microliter sample was injected and performed at 230°C in splitless mode with helium carrier gas flow at 1 ml/min. Chromatography was performed using a DB-5MS capillary column (20 m × 0.18 mm × 0.18 μm) with a 5 m Duraguard column in front. The temperature program started isothermal at 70°C for 2.471 min and then increased to 330°C by a 10.119°C/min ramp and kept for 2.471 min. Mass spectra were collected at 5.6 scans/s with an m/z 50–600 scanning range. The transfer line temperature and the ion source temperature were set to 250 and 230°C, respectively.http://csbdb.mpimpgolm.mpg.de/csbdb/gmd/msri/gmd_msri.html). Ribitol was used as the international standard for quantification.Metabolites were identified by comparing fragmentation patterns with those in a mass spectral library generated on our GC/MS system and an annotated quadrupole GC-MS spectral library from the Golm Metabolome Database (http://sgn.cornell.edu/) and the VegMarks database (http://vegmarks.nivot.affrc.go.jp/). Only markers with minor allele frequency (MAF) > 0.05 were genotyped with the whole accessions  were calculated using TASSEL 2.1 software  3.0.2 were used for statistical analyses. We replaced the values of zero (undetectable) for all metabolites by the smallest non-zero value in the whole dataset  before further association mapping analysis. Correlations among sugars and organic acids and other traits were analyzed in the R statistical software and the results were presented via HemI 1.0. We estimated genetic variance, genetic by environment interaction variance, technical variance, and heritability values according to the method of Xu et al.  or the R statistical Software  among the 17 metabolites revealed that compounds corresponding to a functional classification of the metabolites tended to be positively correlated , with 40, 35 significant associations in 2013, 2014, respectively. We observed at least one MTA on all sugars and organic acids except for threitol. These MTAs were spread unevenly over tomato genome, with all chromosomes carried at least one MTA  and up to 30 MTAs were detected on Chr9. The number of MTAs ranged from zero (no MTAs were observed for threitol) to 38 (citric acid).We assessed population structure of the 174 tomato accession using STRUCTURE 2.3.3 software with 182 SSRs. According to Evanno method , accounting for 11.21% of the phenotypic variation. However, no significant association was detected between this marker and octonol variation in 2013.For the eight sugars and sugar alcohols, 56 MTAs were observed with 31, 43 MTAs in 2013 and 2014, respectively. Among these, 18 MTAs were detected in both years. The largest MTA number was detected for sucrose  and no MTA was detected for threitol. For fructose, nine MTAs were observed in total and two of them were observed both in 2013 and 2014. For sucrose, 16 MTAs were observed and the most significant association was detected on TES835 (Chr3) both in 2013 and 2014, explaining 16.94, 12.12% of the phenotypic variation. The other significantly associated marker was TGS801 (Chr9) and was also detected both in 2013 and 2014, explaining 12.9, 15.17% of the phenotypic variation, respectively. For octonol, it was significantly associated with marker SSR133 (Chr 4) in 2014. This association had a very high significance value (P = 8.27E-07), accounting for 9.46% of the phenotypic variation. Besides, this association was also observed in 2014, representing 5.77% of the phenotypic variation. For malic acid, five MTAs were observed either in 2013 or 2014 (Table P < 0.001). For proline and glutamic acid, the two main amino acids with a high concentration in tomato fruits, four and six MTAs were observed, either in 2013 or 2014, respectively. The two MTAs with a significance value for glutamic acid were TGS827 (Chr3) and TES56 (Chr3) both in 2013, explaining 4.58, 3.23% of the phenotypic variation, respectively. Less MTAs were observed for butanoic acid, gluconic acid, and hexdecanoic acid, with two, one and one MTA, either in 2013 or 2014, respectively.For the nine organic acids, 83 MTAs were detected, with 66, 50 MTAs in 2013, 2014, respectively. Among these, 33 MTAs were detected in both years. For citric acid, 38 MTAs were detected in 2013 or 2014, representing the largest MTAs for all measured metabolites, with at least one MTA for each chromosome. The most significant association was observed on SSR45 (Chr7) in 2013  or 2014 (43 MTAs) with at least two MTAs (myo-inositol) and up to 16 MTAs (sucrose). For the nine organic acids, 83 MTAs were detected in 2013 (66 MTAs) or 2014 (50 MTAs). Fulton et al.  detectedfru9.1/PV on Chr9 was located in less than 0.3 cM away from TGS801, and we observed that this loci was significantly associated with the variation of fructose in 2014 and could explain 8.01% of the variation. fructose6.1/PV was located about 10 cM away from the significantly associated loci TGS2911. This significantly associated loci only explained 3.7% of the phenotypic variation. This could be mainly due to the large genomic distance between the associated loci and QTL (>8 cM). However, it is still possible that this association might be caused be fructose6.1/PV, based on previous GWAS results that tomato genome decays at about 10–20 cM  for glucose near TGS2911. This observation suggests that in the near region of TGS2911, there are either two dependent QTLs/genes or one gene involved in the sugar metabolic pathways. Sucrose was significantly associated with four loci on chr9 . Fulton et al. (suc9.1/PV and suc9.2/PV) for sucrose on Chr9. suc9.1/PV was located about 5 cM away from the significantly associated loci SSR142. suc9.2/PV was located about 7 cM away from the significantly associated loci SSR110. These two significant associations accounted for 12.74, 10.14% of the variation of sucrose in 2014 and could be mainly due to suc9.1/PV and suc9.2/PV, respectively.However, our results still confirmed several reported QTLs on main tomato fruit sugars and organic acids Figure . Fructosn et al.  reportedP < 0.001). Fulton et al. . ca1.1/PR and ca1.2/PR are two QTLs on Chr1 detected in Fulton et al.  were suitable for detecting significant associations with tomato fruit sugars and organic acids. Several formerly identified QTLs, such as JTZ, JZ, and ZZ designed the study. JTZ and YX carried out the main GC-MS analysis and molecular mapping, analyzed the data, and drafted the manuscript. XH, QD, ML, LC participate in the data analysis of sugars and organic acids. YZ participated in genotyping. All authors corrected and approved the final version.This work was supported by the Program for New Century Excellent Talents in University (No. NCET-12-0474), National Natural Science Foundation of China (Grant No. 31301498), Agricultural Science and Technology Innovation and Research in Shaanxi province (Grant No. 2016NY-165) and the National Agricultural Science Foundation (No. 201203002).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To compare enhancement characteristics and image quality of two macrocyclic gadolinium chelates, gadoterate meglumine and gadobutrol, in low-dose, time-resolved MRA of the calf station.100 consecutive patients with peripheral arterial disease (stages II-IV) were retrospectively analysed. Fifty patients were included in each group - 32 men and 18 women for gadobutrol (mean age 67 years) and 34 men, 16 women for gadoterate meglumine (mean age 64 years). 0.03 mmol/kg bw of either gadobutrol or gadoterate meglumine was injected. Gadobutrol was diluted 1∶1 with normal saline (0.9% NaCl) to provide similar injection volume and bolus geometry compared to the undiluted 0.5 M dose of gadoterate meglumine. Signal-to-noise-ratio (SNR), contrast-to-noise-ratio (CNR) and image quality were analysed and compared between the two groups.Mean SNR ranged from 83.0±46.7  to 96.4±64.5  for gadobutrol, and from 37.6±13.8  to 45.3±16.4  for the gadoterate meglumine group (p<0.0001). CNR values ranged from 30.1±20.1  to 37.6±26.0  for gadobutrol and from 14.9±8.0  to 18.6±16.4  for gadoterate meglumine (p<0.0001). No significant difference in image quality was found except for the peroneal arteries (p = 0.006 and p = 0.04). Interreader agreement was excellent (kappa 0.87–0.93)The significantly better enhancement as assessed by SNR and CNR provided by gadobutrol compared to gadoterate meglumine does not translate into substantial differences in image quality in an equimolar, low-dose, time-resolved MRA protocol of the calves. The diagnostic value of contrast-enhanced MR-angiography (CE MRA) for the evaluation of the lower extremity vasculature at 3 Tesla (3 T) is well-established in the literature Evaluation of the relatively small caliber vasculature of the calf station is often impaired by venous overlay due to altered patient hemodynamics. This may result from soft tissue inflammation—a common finding in patients with advanced stages of PAD. Such limitations can be successfully avoided through implementation of time-resolved MRA sequences such as time-resolved imaging of contrast kinetics (TRICKS) 1 relaxivity when compared to other contrast agents. We hypothesized that the latter factor should thus lead to improvements in signal to noise ratio (SNR), contrast to noise ratio (CNR) and image quality Patients suffering from PAD also often present with multiple comorbidities including impaired renal function and are thus at an increased risk of developing nephrogenic systemic fibrosis (NSF). The incidence of NSF is not only related to the molecular structure of the administered gadolinium chelate, with macrocyclic chelates being more stable than linear compounds, but also to the injected dose. Therefore, low-dose injection protocols or nonenhanced MRA The aim of the current investigation was therefore to compare equimolar doses of gadobutrol and gadoterate meglumine with respect to SNR, CNR and image quality in a time-resolved, low-dose MRA protocol of the calf region.Institutional review board approval was obtained for this study. The institutional review board  waived the requirement for informed patient consent for this retrospective study. The information gathered on this retrospective patient population was performed in compliance with HIPAA guidelines. 100 consecutive patients with PAD (Fontaine stages II-IV) who underwent routine MRA of the peripheral vasculature at our institution between October 2008 and March 2011 were included for retrospective data analysis . Either gadobutrol or gadoterate meglumine was utilized as the contrast agent, based upon the clinical necessities of the examination day .All MRA examinations were performed on a 3 T, 32-channel whole-body MR system . To cover the entire field of view (FoV) from the diaphragm to the calves, a dedicated 36-element peripheral angiography matrix coil, as well as 2 body 6-element matrix coils and 2 clusters of the inbuilt spine matrix coil were utilized. Patients were positioned supine feet-first in the MR bore. A 20 G cannula in the left or right antecubital vein was used for contrast agent administration, which was performed with an automated power injector . Detailed scan parameters are summarized in 1 relaxivity of gadobutrol versus gadoterate meglumine is 5.0±0.3 vs. 3.5±0.2 L*mmol−1s−1  Two macrocyclic gadolinium based contrast agents were utilized for this study: gadobutrol  formulated at 1.0 molar (M) and gadoterate meglumine  formulated at 0.5 M. The r2D gradient echo sequence localizers were obtained in coronal and axial planes to allow for planning of the examination. After acquisition of continuous table movement-MRA (CTM-MRA) images, an additional 0.03 mmol/kg body weight of the respective contrast agent was administered at a rate of 1.5 ml/s followed by a 30 ml normal saline (0.9% NaCl) chaser at the same injection rate for time-resolved MRA with interleaved stochastic trajectories (TWIST) of the calf station.Image evaluation was performed offline utilizing a standard DICOM-viewer . Region-of-Interest (ROI) measurements were performed by a single reader for SNR and CNR measurements. The reader was blinded to the contrast agent administered. ROIs were placed in vessel segments in the anterior and posterior tibial as well as peroneal arteries on the pre-contrast scans. Noise calculations were performed by placing a ROI in an artifact-free background area of the subtracted coronal maximum intensity projection images. A ROI was placed in the corresponding vessel at consecutive time points and signal intensity then was measured at the time point of maximum vessel enhancement. The above ROIs were carefully placed in vessel segments displaying homogenous contrast enhancement while avoiding the vessel borders. SNR and CNR were calculated according to the following formulas For the qualitative assessment, two blinded readers assessed image quality on a scale of 1 to 4  within 4 arterial segments in the bilateral lower extremities . Data from both limbs in the patients was pooled, resulting in possible evaluation of 96 (2×48) data points for each territory. Territories in a given patient were excluded if arterial occlusions within a segment led to no significant vascular enhancement, one of the limbs was amputated, or vascular evaluation was not possible secondary to patient motion.Statistical analysis was performed using JMP 9.0 . Continuous variables are expressed as mean, standard deviation (± SD), and range (min–max). Continuous variables for SNR and CNR are expressed as mean and standard deviation. SNR and CNR values between the two groups were compared using a Student t-test after normally distribution of data was confirmed using the Shapiro–Wilk test. A 2-tailed p-value of <0.05 was considered statistically significant. To assess qualitative differences in quality between scans performed with gadobutrol and gadoterate meglumine, median image quality for each reader in 4 arterial segments was computed. Image quality ratings for each reader were compared between images obtained with gadobutrol and gadoterate meglumine utilizing a Mann-Whitney U Test. Inter-reader variability was assessed via Cohen's Kappa statistics. Kappa values greater than 0.75 were taken to represent excellent agreement, values between 0.4-0.75 to represent good agreement, and values below 0.4 as poor agreement.All measurements were completed successfully, and no examinations were excluded due to inadequate image quality. SNR measurements for gadobutrol demonstrated a mean signal intensity of 83.0±46.7 for the peroneal artery, 92.9±58.9 for the posterior tibial artery, and 96.4±64.5 for the anterior tibial artery. Gadoterate meglumine SNR was 37.6±13.8 for the peroneal artery, 41.2±13.8 for the posterior tibial artery, and 45.3±16.4 for the anterior tibial artery. SNR measurements were statistically significantly different for all three vessel segments evaluated  .CNR measurements for gadobutrol in the peroneal artery demonstrated a mean signal intensity of 30.1±20.1 for the peroneal artery, 37.1±26.8 for the posterior tibial artery, and 37.6±26.0 for the anterior tibial artery. Gadoterate meglumine exhibited CNR of 14.9±8.0 for the peroneal artery, 16.9±9.2 for the posterior tibial artery and 18.6±16.4 for the anterior tibial artery. CNR measurements were statistically significantly different for all three vessel segments evaluated  .For reader 1, qualitative assessments were possible for the gadobutrol scans in 91% (87/96) of cases for the anterior tibial artery, 81% (78/96) of cases for the posterior tibial artery, and 90% (86/96) of cases for the peroneal artery. For the gadoterate meglumine scans, these respective assessments were possible in 89% (85/96), (89%) 85/96, and 93% (89/96) of cases. For reader 2, qualitative assessments were possible for the gadobutrol scans in 91% (87/96) of cases for the anterior tibial artery, 80% (77/96) of cases for the posterior tibial artery, and 90% (86/96) of cases for the peroneal artery. For the gadoterate meglumine scans these respective assessments were possible in 90% (85/96), 90% (85/96), and 92% (88/96) of cases. Image quality ratings ranged from values of 1–4 for each reader. Median ratings of image quality are provided in The results of the present study demonstrate superior SNR and CNR for equimolar doses of gadobutrol versus gadoterate meglumine for time-resolved MRA of the calves at 3 T. Our results demonstrate a significant difference in SNR and CNR measurements in all three vessel segments evaluated, with gadobutrol achieving SNR and CNR values up to 100% higher than gadoterate meglumine. However, this did not translate into the expected degree of improved subjective image quality as gadobutrol scans were only rated to have statistically significantly better image quality in one of three assessed vascular segments.1-relaxation rate relative to non-protein binding agents like gadobutrol A previous study by Voth et al. showed equimolar doses of gadobutrol, also diluted to 0.5 M with saline, provided greater image quality for peripheral MRA in all vessel segments from the diaphragm to the calves versus gadoterate meglumine utilizing CTM-MRA. Both contrast agents were injected at a dose of 0.07 mmol/kg bw in this instance and at a constant injection rate of 1.5 ml/sec Szucs-Farkas et al. concluded that gadobutrol did not show significant differences in regards to SNR, CNR or image quality in CE-MRA performed at 1.5 Tesla compared to gadoterate meglumine. Szucs-Farkas et al. did not dilute gadoterate meglumine, but did inject the agents at equimolar doses per bodyweight. The major drawback of that study was the slow injection rates of 0.4 and 0.8 ml/sec for gadobutrol and gadoterate meglumine, respectively. This may have resulted in insufficient bolus definition, particularly in the peripheral vasculature of the calves. The authors concluded that further investigation was warranted to determine whether a higher injection rate would translate into better image quality Our study utilized an equimolar dose of the contrast agents, with dilution of the 1 M gadobutrol 1∶1 with normal saline (NaCl), thus allowing for an equivalent concentration and similar bolus geometry compared to the 0.5 M gadoterate meglumine. Dilution allowed for injection of the same volume of contrast material for both injection protocols, minimizing the potential for technologist error. Thus, using the same technical parameters, gadobutrol performed significantly better than gadoterate meglumine in terms of objective image quality. However, our initital hypothesis that the higher relaxivity of gadoterate would translate into improved diagnostic image quality did not hold true. This is in agreement with prior work by Fink et al. and Haneder et al. Several limitations of our study warrant further discussion. Neither age, gender, nor PAD stage was matched; however, both groups contain similar numbers of male and female patients of similar mean ages. Contrast agent was already present in the vessel segments evaluated on pre-contrast scans due to the prior CTM-MRA, however this possible confounder was equivalently present in both groups. In addition, intra-individual comparisons could not be performed due to the retrospective study design. By definition, retrospective studies are limited, and therefore larger scale prospective studies are required to validate our results.In conclusion, the significantly better enhancement as assessed by SNR and CNR provided by gadobutrol does not translate into improved image quality in an equimolar, low-dose, time-resolved MRA protocol.