Data pertaining to eyes treated with FAc implant for diabetic macular oedema (DMO) was extracted. Intraocular pressure (IOP)-related adverse events were defined as use of IOP-lowering medication, any rise in IOP>30 mm Hg, or glaucoma surgery. Other measured outcomes included visual acuity, central subfield thickness (CSFT) changes and use of concomitant medications.μm.In total, 345 eyes had a mean follow-up of 428 days. Overall, 13.9% of patients required IOP-lowering drops , 7.2% had IOP elevation >30 mm Hg and 0.3% required glaucoma surgery. In patients with prior steroid exposure and no prior IOP-related event, there were no new IOP-related events. In patients without prior steroid use and without prior IOP-related events, 10.3% of eyes required IOP-lowering medication and 4.3% exhibited IOP >30 mm Hg at some point during follow-up. At 24 months, mean best-recorded visual acuity increased from 51.9 to 57.2 letters and 20.8% achieved ≥15-letter improvement. Mean CSFT reduced from 451.2 to 355.5 While overall IOP-related emergent events were observed in similar frequency to FAME, no adverse events were seen in the subgroup with prior steroid exposure and no prior IOP events. Efficacy findings confirm that the FAc implant is a useful treatment option for chronic DMO. Without treatment, over half of all patients who develop DMO will lose two or more lines of visual acuity within 2 years.post hoc analysis of the Diabetic Retinopathy Clinical Research Network Protocol I study, 40% of eyes had an insufficient response  from baseline) to anti-VEGF therapy at 3 months.8 In the Studies of Ranibizumab Injection in Subjects with Clinically Significant Macular Edema (ME) With Center Involvement Secondary to Diabetes Mellitus (RIDE and RISE), 13% of patients experienced no change or a decrease in visual acuity score at Month 24 following 0.5 mg ranibizumab therapy.5 Anti-VEGF therapies also require regular follow-up and usually multiple injections, resulting in a substantial treatment burden for patients and hospital eye services.9Although most patients respond to anti-VEGF therapy, a proportion of eyes do not show an improvement in vision or even lose vision. In a 12 One long-acting steroid preparation for the management of DMO is 0.2 μg/day fluocinolone acetonide (FAc) intravitreal implant , which has proven to be efficacious for up to 36 months.13 However, intraocular pressure (IOP) elevations and cataract formation, which are known side effects of intravitreal corticosteroid therapy,17 were also observed with 0.2 μg/day FAc. In patients who were phakic at baseline, development of cataract was shown to occur following FAc implantation in a substantial proportion of the FAc-treated arm compared with the sham control arm, and increased IOP was also observed more frequently in the actively treated arm.10Intravitreal corticosteroid implants are another effective treatment option for DMO and, as the biological activity of such implants lasts longer, a reduced frequency of injections would be expected compared with anti-VEGF monotherapy.μg/day FAc implant were replicated in real-world settings, particularly with respect to adverse events, the present electronic medical record (EMR) based study examined safety and efficacy outcomes using data acquired from 14 clinical sites in the UK.In order to evaluate if the clinical trial outcomes with 0.2 All 14 clinical sites that provided data for this study used a single EMR system . A structured template was used as part of the retina module to record and document the findings, and thus the data that are collected are more similar to those obtained in prospective clinical trials and studies. The lead clinician and Caldicott Guardian (responsible nominee for data protection) at each NHS Hospital gave written approval for anonymised data extraction. This study was conducted in accordance with the Declaration of Helsinki and the UK’s Data Protection Act.μg/day FAc implant for the licenced indication of chronic DMO were identified by Medisoft Limited from the EMR system of each participating centre and extracted from each site, before being pseudoanonymised prior to amalgamation into a single dataset. Automated scripts were used to identify any patient treated with 0.2 μg/day FAc implant and not flagged as a test patient. Data were then extracted from the entire record of eligible patients so that observations and treatments before and after 0.2 μg/day FAc treatment were included within the analysis. A two-step approach was used to focus on DMO patients: first, non-diabetic patients were excluded and, subsequently, diabetic patients with no DMO diagnosis were excluded. Data available in the extracted set covered baseline demographics and disease characteristics including: prior treatment for DMO; the incidence of IOP elevation and management; additional ocular treatments administered post 0.2 μg/day FAc implant; vision outcomes; and change in central subfield foveal thickness (CSFT).The present analysis was conducted using data extracted in August 2016. Data from patients who had received the 0.2 Multiple data extracts are permitted from the EMR by the current protocol approval, up to 2018.The range of baseline vision distribution for inclusion was not specified at the outset of the study, as this was not a clinical trial. Treatment was carried out at the clinicians’ discretion with a range of 5–85 Early Treatment Diabetic Retinopathy Study (ETDRS) letters.μg/day FAc treatment were: percentage of treated eyes that had exhibited IOP increase ≥10 mm Hg and IOP elevation above 30 mm Hg; percentage of patients diagnosed with glaucoma or requiring IOP-lowering medication; and percentage of patients requiring trabeculoplasty and trabeculectomy/glaucoma surgery. IOP-related outcomes for patients who completed 12- and 18-month follow-up in this study were compared with the same outcomes at 12 and 18 months in the Fluocinolone Acetonide for Diabetic Macular Edema (FAME) study. Visual outcomes were also analysed from the database, including: change in vision distribution assessed by ETDRS letters; mean Best-Recorded Visual Acuity (BRVA); percentage of patients achieving ≥6/12 vision; percentage of patients with vision stability or improvement; and percentage of eyes gaining ≥15 ETDRS letters. Baseline data were included if there was a later data point for comparison. Data were excluded if only baseline data or only follow-up data were available. Baseline visual acuity (VA) is the last non-missing value taken on or before the initial date of 0.2 μg/day FAc implant administration. Every non-missing VA assessment collected after the initial date of 0.2 μg/day FAc administration was assigned a follow-up visit using study day number  and visit windows. In addition, drug utilisation in the 12 months prior to and following 0.2 μg/day FAc implant for the treatment of DMO was analysed. End points were captured based on data captured in EMR.IOP-related end points analysed following the 0.2 11 All comparisons were descriptive; no formal statistical analysis was undertaken.Data from this real-world safety study were compared with results for patients with chronic DMO from the pivotal pre-registration FAME study at equivalent time points.Data were available for 345 DMO eyes  with a mean duration of follow-up of 428 days (range 0–919 days).μg/day FAc implants at the same time as cataract surgery. Prior to receiving the 0.2 μg/day FAc implant, 14.2% of eyes had already received IOP-lowering medication; 3.5% of eyes had IOP level >30 mm Hg at baseline and 0.3% of eyes had already required trabeculectomy or glaucoma surgery.Mean age of treated patients was 68.5 years; 53.1% were male and 58.5% of patients had proliferative diabetic retinopathy at baseline. Most treated eyes (89.6%) were already pseudophakic and a further 7.2% of patients (25 eyes) received 0.2 The majority of treated eyes had received prior therapy for DMO (91.6%); 28.4% of treated eyes had received prior macular laser therapy and 84.6% of treated eyes had received at least one prior intravitreal treatment, with a mean of 7.36 prior intravitreal treatments. In patients with any prior intravitreal treatment, 32.8% had prior intravitreal steroids  and 78.6% had prior anti-VEGF . In the majority of treated eyes (84.4%) baseline vision was <70 letters.At baseline, mean BRVA was 51.9 ETDRS letters ; 7.2% experienced an IOP elevation above 30 mm Hg and there was a single patient (0.3%) who required IOP-lowering surgery (this patient had a prior IOP-related event). The overall incidence of glaucoma (diagnosis based on report of glaucomatous cupping/notching at optic disc exam) was 1.2%.At last observation, 13.9% of patients in the current study required IOP-lowering drops , intravitreal treatment  and retreatment with the FAc implant . Of the eyes that received additional intravitreal treatment post FAc implant, 4 (1.2%) received bevacizumab; 47 (13.6%) aflibercept; 61 (17.7%) ranibizumab; 8 (2.3%) dexamethasone; and 8 (2.3%) triamcinolone. Overall, the mean number of intravitreal injections was 7.4 before FAc administration and 4.4 after FAc administration. For specific additional intravitreal treatments post FAc implant, the mean number of injections was 2.5 for bevacizumab; 4.0 for aflibercept; 4.5 for ranibizumab; and 1.3 for triamcinolone. One patient retreated with 0.2 μg/day FAc injection had a concomitant uveitis diagnosis; the other patient had a history of pars plana vitrectomy 2 months before the second injection.The majority of eyes (64.3%) were given no additional treatments for DMO post FAc injection. Where used, additional treatments included macular laser therapy  to 56.4 letters at 18 months (n=120). At 24 months, mean BRVA was 57.2 letters (n=53). A similar trend was also demonstrated in the subgroup of pseudophakic patients. BRVA gain was maintained in patients with 12 or 18 months’ follow-up  had a mean BRVA of 51.8 letters at baseline. This increased by 3.2 letters to 55.0 letters at last observation. Patients who did not receive any additional treatments post FAc injection (n=206) had a mean BRVA of 52.0 letters at baseline. This increased by 3.0 letters to 55.0 letters at last observation.Mean BRVA for eyes with baseline and at least one later data point for comparison increased from 51.9 letters at baseline (ollow-up . Althoug implant . Patientn=160), 81.6% at 18 months (n=120) and 86.7% at 24 months (n=53), and remained above 74.0% over the entire period of analysis. The proportion of patients with 6/12 vision or better increased from 18.1% at baseline to 39.2% at 18 months and 39.6% at 24 months, and remained above baseline over the period of analysis (The percentage of eyes with vision stability or improvement (defined by any gain or any loss less than four letters from baseline) was 78.7% at 12 months . A mean reduction in CSFT of 95.7 μm was observed over the period of analysis (P<0.001), with a mean CSFT at last observation of 355.5 μm.Mean CSFT at baseline was 451.2 μg/day FAc implant and the overall use decreased to 32.8% in the 12 months after 0.2 μg/day FAc implant. Utilisation of anti-VEGF treatment decreased by 51.3% laser treatment decreased by 2.1% and steroid treatment decreased by 2.5% in the 12 months after 0.2 μg/day FAc implant, compared with the 12 months before. μg/day FAc implant with those in the 12 months prior to 0.2 μg/day FAc implant.Overall, 85.7% of eyes were treated with any intravitreal treatment or laser  in the 12 months prior to receiving 0.2 μg/day FAc implant for the treatment of chronic DMO. In this cohort, on average, the majority of treated eyes had moderate visual impairment at entry into this database and had received intravitreal therapy, including anti-VEGFs and other corticosteroids, before treatment with the FAc implant. The main finding of our analysis was the demonstration of a favourable safety profile, with important improvements in VA and retinal morphology.This study, which used the highly structured EMR data from 14 UK retina centres, was undertaken to assess real-life outcomes, with a particular focus on IOP-related adverse events, following the use of 0.2 μg/day FAc implant treatment that were included in the EMR dataset was different and vastly broader than of the FAME study11 and in other landmark clinical trials of intravitreal therapies for DMO.12 In the real-life setting, we observed that treatment was initiated in eyes with VA ranging from 5 to 85 ETDRS letters, compared with a range of 19–68 ETDRS letters in the FAME study and 24–73 ETDRS letters in the RISE/RIDE trial.The range of VA of eyes at the time of 0.2 μg/day FAc treatment, as well as those requiring drop initiation) and 0.3% requiring glaucoma surgery at last observation. In the overall study population, the increase in mean IOP observed was gradual and remained under 20 mm Hg throughout the period of analysis. Our real-world data show that the proportion of patients requiring IOP-lowering medication or glaucoma surgery at 18 months was lower than that in the FAME study at 18 months. In addition, the incidence of glaucoma was low in this study (2.4% in 18-month completers). Future analyses of data collected following 0.2 μg/day FAc treatment could include exploration of the relationship between IOP and lens status and thus provide further insight into the extent of the effect of cataract removal on IOP.Overall, the side-effect profile demonstrated in this study was in line with the known safety profile for intravitreal corticosteroids. The majority of IOP increases did not require medical management, as demonstrated by only 13.9% of patients requiring IOP-lowering drops  rather than objective refractions at each visit. This is likely to underestimate the actual changes in vision. However, it may better reflect the visual outcomes that patients actually experience following treatment and is reassuring for the outcomes that ophthalmologists can advise their patients to expect.A potential limitation is the interim and open-label nature of this analysis. Although the data were entered prospectively, they were analysed retrospectively and no further information could be obtained if there were missing data points, such as optical coherence tomography thickness; although subsequent analyses are likely to provide further information on the long-term tolerability and efficacy of 0.2 μg/day FAc implant has the potential to considerably improve patients’ quality of life, owing to improved vision and a decreased requirement for additional therapies/visits. Despite poor starting vision and receiving prior therapy, treatment with the FAc implant was associated with sustained or improved vision for 86.7% of patients at 24 months. The majority of patients did not receive additional treatments, however, it should be noted that 35.7% of patients received additional treatments post FAc injection. Nevertheless, visual outcomes were similar for patients regardless of if they received additional intravitreal treatment or not. As most patients had received intravitreal anti-VEGF prior to the FAc implant, the visual improvements on top of previous improvements in VA are important. These results are especially noteworthy, since the patient population in this study may have been at a later stage of disease than was studied in the RISE and RIDE studies for intravitreal ranibizumab.21 Another important quality of life consideration is maintenance of functional vision; the legal minimum requirement for driving in the UK is binocular VA of 6/12.22 The proportion of patients with 6/12 vision or better in the treated eye increased from 18.1% at baseline to 39.6% at 24 months, and remained above baseline over the period of analysis.Treatment with a single 0.2 μg/day FAc for the treatment of chronic DMO in routine clinical practice. The FAc implant appears to be a valuable therapeutic approach for patients with chronic DMO refractory to other treatment options, with a predictable and manageable side-effect profile that is more favourable in the absence of prior IOP-related events.In conclusion, the results of this EMR audit provide further evidence of the tolerability and efficacy of 0.2


Smoking is associated with an increased incidence of hormone receptor positive breast cancer. Data regarding worse breast cancer outcome in smokers are accumulating. Current literature regarding the impact of smoking on breast cancer characteristics is limited. We evaluated the impact of smoking on breast cancer characteristics and outcome.This was a retrospective single center study. All women diagnosed from 4/2005 through 3/2012 and treated in our institute for early, estrogen receptor positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer, whose tumors were sent for Oncotype DX analysis were included. Medical records were reviewed for demographics, clinico-pathological parameters, treatment and outcome. Data regarding smoking were retrieved according to patients’ history at the first visit in the oncology clinic. Patients were grouped and compared according to smoking history (ever smokers vs. never smokers), smoking status (current vs. former and never smokers) and smoking intensity (pack years ≥30 vs. the rest of the cohort). Outcomes were adjusted in multivariate analyses and included age, menopausal status, ethnicity, tumor size, nodal status and grade.p = 0.045, 8.3% vs. 3.5%, p = 0.031, respectively). Smoking had no other impact on histological characteristics. Five-year disease free survival and overall survival rates were 95.7% and 98.5%, respectively. Smoking had no impact on outcomes. Adjusted disease free survival and overall survival did not influence the results.A total of 662 women were included. 28.2% had a history of smoking, 16.6% were current smokers and 11.3% were heavy smokers. Smoking had no impact on tumor size, nodal involvement and Oncotype DX recurrence score. Angiolymphatic and perineural invasion rates were higher in current smokers than in the rest of the cohort (10.4% vs. 5.1%, Smoking had no clinically significant influence on tumor characteristics and outcome among women with estrogen receptor positive, HER2 negative, early breast cancer. As the study was limited to a specific subgroup of the breast cancer population in this heterogeneous disease and since smoking is a modifiable risk factor for the disease, further research is required to clarify the possible impact of smoking on breast cancer. There are accumulating data regarding the association between smoking and breast cancer. Mammary tissue is capable to uptake many tobacco carcinogens, including polycyclic aromatic hydrocarbons, aromatic amines and N-nitrosamines. In vitro studies and animal models found that several tobacco carcinogens may induce breast tumors , 2 and mThe existing literature links smoking with increased breast cancer incidence –13. The All-cause mortality rate is higher in smokers with breast cancer compared to non-smokers –18; howeRecent meta-analysis comprising almost 40,000 patients found smoking increases risks of all-cause and breast cancer specific mortality in patients with breast cancer .Smoking is a significant health problem and one of the few potentially modifiable risk factors for breast cancer development. Information regarding the impact of smoking on breast cancer characteristics is scarce. The aim of this study was to evaluate the influence of smoking on breast cancer characteristics and outcome.We chose to focus on women with early stage, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) breast cancer as this group represent the majority of breast cancer patients , 28 and A retrospective single center cohort study was conducted. The study protocol was approved by the Rabin Medical Center Ethics Committee . All women treated in our institute with ER positive, HER2 negative early breast cancer, who were diagnosed between 4/2005 and 3/2012, and whose tumors were sent for ODX analysis were included. The study cohort was generated using a registry of patients whose tumors were referred to ODX analysis and is kept in our medical center. As data were analyzed anonymously, no consent was given.The medical records were reviewed up to 8/2015 for demographics, treatment and outcome. Data regarding clinical-pathological parameters were retrieved from patients’ pathological reports. Data regarding history of smoking, number of pack years and smoking status (current vs. former smoker) at breast cancer diagnosis were systematically collected according to the patients’ history during the first visit at the oncology clinic. We defined current smokers as patients who actively smoked at the time of breast cancer diagnosis. Patients with history of smoking were defined as ever smoker.Patients were grouped and compared according to their history of smoking (ever vs. never smokers), smoking status (current vs. former and never smokers), and smoking intensity (≥30 vs. <30 pack years). Comparisons included tumor size, nodal involvement, stage, ODX recurrence score (RS) and histological characteristics including: ER, progesterone receptor (PR), HER2, grade, angiolymphatic and perineural invasion, Ki67 percent, P53 and histological subtype.ER and PR staining were reported using the modified version of the H-score method: 1 x percentage of weakly staining nuclei +2 x percentage of moderately staining nuclei +3 x percentage of intensely staining nuclei)/100, yielding a range of 0 to 3. Ki67 staining was reported as a percentage of positively stained nuclei (0 to 100%). HER2 negativity was defined as an immunohistochemistry (IHC) test score of 0 or 1. If the IHC score equaled 2, negativity of HER2 was determined according to the fluorescence in situ hybridization test per the American Society of Clinical Oncology guidelines at the test time.Survival time was defined as time from tissue diagnosis to date of last followup or death. Disease free survival (DFS) was defined as the time between surgery to event (recurrence or death) or end of followup. Duration of followup was determined according to the date of last followup in the chart. Date of recurrence was either the date of biopsy from breast or lymph node  or the date of abnormal imaging (for distant recurrence). Patients’ vital status was ascertained through Israel’s ministry of interior database.The statistical analysis was generated using SAS Software, Version 9.4. Continuous variables were presented by mean ± SD. Categorical variables were presented by . T-test was used to compare the value of continuous variables between study groups. Chi-Square (for more than two groups) or Fisher’s exact test (for two groups) were used to compare the value of categorical variables between study groups.p-values less than 0.05 were considered statistically significant.Overall survival (OS) was assessed by Kaplan-Meier survival analysis, with the log-rank test. BCSS and DFS were assessed by the Cox proportional hazards model; with the Fine and Gray correction for competing risks (the competitors were non-cancer death for BCSS and death without recurrence for DFS). Multivariate analysis for OS, BCSS and DFS adjusted for age, menopausal status, ethnicity and tumor characteristics including tumor size, nodal involvement and grade were assessed by the Cox proportional hazards model. Two-sided A total of 671 patients with early breast cancer whose tumor was sent to ODX analysis were found. Nine men were excluded, remaining 662 women who were included in the study cohort. Median age was 61 years (range 34–85). 78% women were postmenopausal. Most patients were Ashkenazi Jews (49.4%), followed by Sephardic Jews (41.5%), other ethnicity (7.0%) and Arabs (2.1%).p < 0.001), and were more likely to be pre-menopausal  women, smoking status in 52 (7.9%) women and number of pack years in 77 11.6%) women. History of smoking was present in 173 (28.2%) women, and 101 (16.6%) women were current smokers at the time of breast cancer diagnosis. 66 (11.3%) women were heavy smokers and the median pack years was 23.5 (range 1–140). Patients characteristics and risk factors according to smoking history and status are presented in Table 1.6% womeHistory of invasive and non-invasive breast cancer was documented in 11.2% and 2.0% of the women, respectively. Nine percent of the women had a history of malignancy other than breast cancer. Personal history of benign breast disease was noted in 9.1%. Family history (first and second degree) of breast cancer and family history of any other cancer were noted in 39.7% and 58.3% of the women, respectively.p = 0.363 and p = 0.089, respectively).Breast cancer diagnosis was established by screening in the majority of cohort population (83.1%). Screening rate was not associated with history of smoking or active smoking status .The most common histology was invasive ductal carcinoma (IDC) (80.8%), followed by invasive lobular carcinoma (ILC) 12.4%). Tumors were well, moderately and poorly differentiated in 16.7%, 65.0% and 18.3%, respectively. Perineural and angiolymphatic invasion were noted in 4.4% and 6.0% of the women, respectively. Intensity of IHC staining of ER and PR are detailed in Table .4%. TumoMedian ODX score was 17 (range 0–88) with 50.6%, 38.3% and 11.1% of the patients had low (0–17), intermediate (18–30) and high (≥31) RS, respectively.p = 0.045, 8.3% vs. 3.5%, p = 0.031, respectively).Tumor characteristics according to the evaluated groups are depicted in Tables Adjuvant hormonal treatment was administered to 97.7% women, most commonly starting with tamoxifen. Most women (74.4%) did not receive adjuvant chemotherapy. Adjuvant treatment with docetaxel and cyclophosphamide was administered to 11%, anthracycline based chemotherapy without taxane was administered to 9.4%, a combination of anthracycline with cyclophosphamide followed by a taxane to 3.7% and other combinations to 1.5% of the women. History of smoking and active smoking were not associated with adjuvant hormonal or chemotherapy treatment.p = 0.036). Accordingly, the estimated 5-year DFS rates for all patients were 95.7% and 96.6% for patients with low RS, 95.6% for intermediate RS and 91.8% for high RS. Five-year DFS rate was significantly different between patients with low and high RS . History of smoking and smoking status were not associated with recurrence rate . DFS rates were not associated with history of smoking , smoking status  and number of pack years .Median follow up was 61.9 months (range 1.7–114.6). During this period, 13 (2%) women died of breast cancer, 14 (2.1%) died of other causes and 635 (95.9%) remained alive. Outcome according to smoking groups are depicted in Table p = 0.742), and number of pack years . Calculation of HR for OS according to smoking status was not applicable. Five-year BCSS was 98.5%. BCSS rates were not associated with smoking status  and number of pack years . Calculation of HR for BCSS according to smoking status was not applicable.Five-year OS rate was 98.5%. OS rates were not associated with history of smoking  and perineural invasion (n = 9) compared to the rest of the study cohort. However, due to the low numbers of patients with these histopathological characteristics, the analysis for this population is limited. Tumor burden, ODX RS and other histological characteristics were not associated with smoking. Lack of differences in traditional prognostic factors such as tumor size, nodal involvement, intensity of IHC stain, grade and Ki67 percent are in line with similar ODX RS in all groups.We evaluated the associations between smoking and ER positive, HER2 negative early breast cancer characteristics and outcome. Current smokers had significantly higher angiolymphatic  and physical activity, which have been shown to be associated with breast cancer, were limited and therefore were not adjusted for. Second, smoking history was acquired during the first visit at the oncology clinic and is subjective to recall and reporting biases. Moreover, information regarding smoking status during the followup period was missing, which presents a limitation for outcome analysis according to smoking status. However, we believe the women who were included in this study were unlikely to start smoking given a median age of 61 years. Furthermore, the change in number of heavy smokers during the median followup of 5 years is also probably insignificant. Third, passive smoking, which might also have impact on breast cancer , 34, wasStrengths of this study include the large patient cohort. Furthermore, the chart review included detailed, individual patient data, lacking in registry-based studies. The correlation between IHC staining and the ODX ER, PR and HER2 (according to RT-PCR) results, as well as the correlation between ODX RS and the DFS of the study population add to the reliability and validity of the findings.In this study cohort, smoking had no clinically significant impact on tumor characteristics and outcome among women with ER positive, HER2 negative early breast cancer. Of note, breast cancer is a heterogeneous disease and these results are limited to a specific subgroup of patients. As smoking is a common health problem and an established modifiable risk factor for breast cancer development, further studies are needed to elucidate the possible impact of smoking on breast cancer patients.


The dominant bacteria phyla included Proteobacteria (36.0%), Planctomycetes (15.4%), Chloroflexi (9.7%), Bacteroidetes (7.7%), Firmicutes (4.4%), Acidobacteria (2.5%), Actinobacteria (1.8%) and Synergistetes (1.3%), while the dominant genera included Thauera (3.42%) and Dechloromonas (3.04%). The absence of methanogens indicates that the microbial community was perfectly retained in the hydrolysis stage instead of in the methane-producing stage.Low-energy cost wastewater treatment is required to change its current energy-intensive status. Although promising, the direct anaerobic digestion of municipal wastewater treatment faces challenges such as low organic content and low temperature, which require further development. The hydrolysis-aerobic system investigated in this study utilized the two well-proven processes of hydrolysis and aerobic oxidation. These have the advantages of efficient COD removal and biodegradability improvement with limited energy cost due to their avoidance of aeration. A pilot-scale hydrolysis-aerobic system was built for performance evaluation with actual municipal wastewater as feed. Results indicated that as high as 39–47% COD removal was achieved with a maximum COD load of 1.10 kg/m Wastewater treatment accounts for a large amount of the energy load in society as a whole. It is estimated that 3–4% of total U.S. electricity is consumed for the movement and treatment of water and wastewater . A simil4 from organics, is a perfect alternative choice for wastewater treatment [Wastewater treatment, which is mainly based on the conventional active sludge process (CAS), is criticized as energy-intensive for its heavy aeration. Based on a full-scale plant energy audit, energy as high as 50% was used to supply air for aeration tanks during the CAS process. The anaerobic digestion (AD) process, which avoids aeration and meanwhile recovers energy in the form of CHreatment . Based oreatment . Namely,4 in a more conventional way for energy recovery [Multiple measures have been considered to solve this problem, such as enhancing the anaerobic methane-producing process. The most viable idea is the use of the anaerobic membrane bioreactor (AnMBR), which has been thoroughly investigated in past decades . The AnMrecovery . Althoug2, were generated and finally converted into CH4. For the first stage of AD, hydrolysis has been widely used as a biological pre-treatment. Hydrolysis can not only partially remove COD by fermentation and maybe also respiration of some of the hydrolysis products, but biodegradability can also be improved. Hydrolysis has been used for a lot of refractory feed, including both solid and liquid waste such as lignocellulosic biomass  [The hydrolysis-aerobic hybrid treatment investigated in this study combined the two well-proven processes of hydrolysis and aerobic oxidation, which was expected to achieve the advantages of the two processes. Due to the limitations of anaerobic methane production mentioned above, part of AD—namely hydrolysis—was applied and combined with aerobic post-treatment. Based on the individual bacteria species, the anaerobic process can be divided into three stages, including hydrolysis, acidogenesis and methanogenesis . Hydrolye straw) , excess e straw) , food wae straw)  and refre straw)  and the e straw) . The inhe straw) . MoreoveIn this study, a pilot-scale hydrolysis-aerobic system was built for performance evaluation with actual municipal wastewater as feed. The influence of the COD load on hydrolysis was investigated. The bacterial community structure of the hydrolysis system was analyzed using high-throughput sequencing.The performance of hydrolysis-aerobic treatment was evaluated using a pilot-scale hydrolysis reactor  and aero3. Pilot-scale experiments lasted for approximately 45 days and had four stages. During the pilot experiment, temperature was maintained around 25 °C. The first stage was a start-up with approximately 50 h of hydraulic retention time (HRT). After 16 days of operation, HRT was reduced to 21 and 12 h in stage II and stage III with COD increasing, respectively. To evaluate the limitation, HRT was reduced further to 5 h in stage IV until the operation performance collapsed. Actual municipal wastewater after the coarse filter of Caoxian WWTP was taken as feed. The BOD/COD of municipal wastewater feed was as low as about 0.2, due to some industrial wastewater flowing into WWTP. Sludge from the thickening tank was inoculated into the hydrolysis reactor with a final concentration of 25 g/L. The effective volume of the hydrolysis reactor is 16.5 m4-N were determined using colourimetric techniques with a HACH spectrophotometer . Illumina HiSeq  sequencing was applied to analyze the microbial consortium of the last stage sludge from the hydrolysis reactor. The procedures used are as follows: (1) The total genomic DNA was extracted using a DNA extraction kit  according to the manufacturer’s instructions; (2) PCR amplification was performed using specifically synthesized primers with a barcode  in the ABI GeneAmp® 9700 system  using the following programme: 5 min of denaturation at 95 °C followed by 30 cycles of 30 s at 95 °C (denaturation), 30 s for annealing at 58 °C and 25 s at 72 °C (elongation), with a final extension at 72 °C for 7 min, and polymerase chain reaction (PCR) products were saved for Illumina HiSeq sequencing; and (3) high-throughput sequencing was performed using the Illumina HiSeq 2500 platform . The chemical oxygen demand (COD) and NH3·d. At the start, there was little to even negative COD removal due to inoculum sludge cell lysis and the release of organics. After 8 days of acclimatization, hydrolysis took over the main reaction and COD removal reached 40~50%. At the start-up stage, the total average COD removal was 25.1%. During stages II and III, the COD load increased to 0.34 kg/m3·d and 0.71 kg/m3·d. Meanwhile, the COD removal also increased to averages of 39.3% and 47.7%. The influence and effluence COD during pilot experiments is shown in As shown in 3·d with a very short HRT of 4.97 h. It should be noted that the hydrolysis performance was negatively impacted in this condition and the COD removal was only 20.2%. The main reason for the collapse of COD removal is probably the loss of microbial sludge in hydrolysis reactor due to the short HRT and high up-flow velocity. Recent research reporting granular hydrolysis sludge with much higher settleability was potential solution to improve performance of hydrolysis reactor, which could be investigated in further research.In the last stage, stage IV, the COD load increased to 1.10 kg/mThe performance of the hydrolysis-aerobic system (stages III and IV) is illustrated in 4-N reduction was observed (20.3 ± 4.8 mg/L after hydrolysis with influent of 19.3 ± 6.1 mg/L). Nitrification occurred in subsequent aeration process and NH4-N decreased to 2.9 ± 1.0 mg/L in final effluent.In comparison, at stage IV after hydrolysis and the final effluent, the COD of influent was 242.0 ± 122.8 mg/L, 201.5 ± 88.4 mg/L and 48.0 ± 8.2 mg/L. The removal ratios of hydrolysis and the total hydrolysis-aerobic system were 15.1 ± 5.1% and 75.8 ± 12.0%, respectively. The COD removal achieved through hydrolysis was remarkably limited due to the high COD load and the very short HRT over-reactor limits. Although the total COD removal of stage IV is close to that of stage III, its aeration energy consumption was probably higher than that of stage III. Furthermore, little nitrogen was removed by hydrolysis. No obvious NH2/kWh energy input. Based the roughly estimation, the energy saving by COD removal of hydrolysis process could be as high as 0.11~0.12 kWh/m3, indicating its advantage over conventional process. The other potential advantage is to improve biodegradability by degrade complex organic compounds into small molecules during hydrolysis.From the perspective of cost saving, the hydrolysis-aeration hybrid system demonstrates its potentials on two advantages. The first is energy saving by degrading part of organics during hydrolysis process, which otherwise would be removal by energy-intensive aeration process e.g., about 105~120 mg/L COD was removal during hydrolysis (stages II and III). Here we assume the energy for aeration was providing 1 kg OProteobacteria (36.0%), Planctomycetes (15.4%), Chloroflexi (9.7%), Bacteroidetes (7.7%), Firmicutes (4.4%), Acidobacteria (2.5%), Actinobacteria (1.8%) and Synergistetes (1.3%). These phyla were also identified by other researchers as the dominant bacteria phyla for wastewater treatment [2 through aerobic oxidation [The structure and diversity of bacterial communities in the hydrolysis reactor were revealed using high-throughput sequencing (HiSeq). Analysis of both the phylum and genus levels of the bacterial community is shown in reatment . It is romycetes .4%, Chloxidation . Firmicuxidation . The hydThauera (3.42%), Dechloromonas (3.04%), Rubinisphaera (1.05%), Nitrosomonas (0.98%), Gemmata (0.66%), Desulfobacter (0.65%), Blastopirellula (0.64%), Ornatilinea (0.63%), Reyranella (0.56%), Thiobacillus (0.48%), Longilinea (0.48%). The genus Thauera belongs to the Betaproteobacteria class and the Proteobacteria phylum. It had a denitrification capacity and is widely distributed in wastewater treatment plants, rivers and polluted pools [Dechloromonas frequently demonstrated a capacity to degrade aromatic compounds such as benzene, and this was related to nitrogen removal [Nitrosomonas was strictly of the ammonia-oxidizing bacterial (AOB), indicating the potential for nitrosification [Desulfobacter is a genus of sulfate-reducing bacteria (SRB) that utilise sulfate as an electron accepter and degrade aromatic compounds. Together with Desulfobacula, it was classified as part of the Proteobacteria phylum, Deltaproteobacteria class, Desulfobacterales order and Desulfobacteraceae family. During hydrolysis, no aeration reduced the SO42− reduction and inhibited SRB abundance and diversity [Longilinea of the Anaerolineae class and Thiobacillus of the Betaproteobacteria class were reported to degrade refractory organics including naphthaline and SCN−.The hydrolysis processes required the presence of a diverse group of bacteria, which were probably closely dependent on each other. There were as many as approximately 200 genera identified in the hydrolysis system. The utilisation of actual wastewater increased the complexity of the microbial niche and led to high diversity. As high as 87.4% of the bacteria were unclassified and even unknown based on genus-level analysis. As shown in ed pools . It is a removal . Further removal . Nitrosoiversity . LongiliMethanomassiliicoccus was identified with a very low abundance of 0.0096%. Both the absence of methanogens and the process performances indicated that the microbial community was perfectly retained within the hydrolysis stage instead of entering into the methane-producing stage. Moreover, it should be noted that microbial community structure analysis by HiSeq was performed only for the last stage with single sampling. The evolving of microbial community structure could be revealed by further research with various sampling over different stages and it would be more informative approach to provide microbial information. Archaeal diversities and communities were also investigated. No methanogens were found as dominant and only 3·d. The microbial community in the hydrolysis reactor was analyzed. The dominant bacteria phyla included Proteobacteria (36.0%), Planctomycetes (15.4%), Chloroflexi (9.7%), Bacteroidetes (7.7%), Firmicutes (4.4%), Acidobacteria (2.5%), Actinobacteria (1.8%) and Synergistetes (1.3%). The dominant bacteria genera included Thauera (3.42%) and Dechloromonas (3.04%). High microbial diversity was observed with actual wastewater as feed, indicating a large proportion of genera that needs to be investigated further. The absence of methanogens indicates that the microbial community was perfectly retained in the hydrolysis stage instead of in the methane-producing stage.The hydrolysis achieved effective pre-treatment with 39–47% COD removal in the hybrid hydrolysis-aerobic process for the low-cost treatment of municipal wastewater. The performance of the pilot-scale system was inhibited when the COD load increased to 1.10 kg/m


Introduction: Coronary artery disease is the leading cause of death worldwide andelectrocardiogram (ECG) is a reliable diagnostic tool to determine a myocardial infarction. Thepresent study tried to compare the relationship between the ECG findings and angiographicfindings in patients with acute anterior myocardial infarction.Methods: Seventy-four patients with acute anterior ST elevation myocardial infarction (Ant-STEMI) presenting to the emergency room in the first 12 hours after the onset of symptoms werestudied. Upon admission, a full 14-lead ECG (including leads V3R and V4R) were performed.Angiographic and ECG findings, as well as clinical outcome were compared between two groups.The statistical tests including Chi-square and independent t-test were used for data analysis.Results: Small conus branch was seen in 52 (70.3%) and large conus in 22 ( 29.7%) patients. STEin right-sided leads and heart failure were significantly higher in small conus branch group versuslarge conus branch . Therewas no significant difference in mortality rate between the two groups . There was a significant difference in major adversecardiac events (MACE) between the two groups .Conclusion: In patients with anterior MI, small conus branch was associated with higher rate ofmajor adverse cardiac events mostly because of increased rate of acute heart failure. STE in lead V4R can indicate right ventricular infarction in patients with inferior infarction, which is associated with a poor prognosis and can lead to arrhythmias and conduction disorders and VF.9Elevation of ST-segment in leads V3R and V4R has also been reported as an occasional finding in some patients with anterior ST elevation myocardial infarction  often supplies blood to the right ventricular outflow tract. Previous studies have reported that specific ECG changes  appear in the event of a blockage or narrowing of the conus branch.15The basal portion of the interventricular septum is supplied with blood by septal branches of LAD, alone or in combination with the conus branch. The presence of a large conus branch may protect the right side of the interventricular septum which manifests with the lack of STE in lead V1. If a small conus branch is present, blood is supplied to both sides of the interventricular septum by LAD artery branches, hence interventricular septum is left unprotected during LAD occlusion which is indicated with STE in lead V1.16Researchers also examined the relationship between RCA conus branch and pattern of STE in lead V1 and V3R during anterior MI. The patients were divided into two groups based on the STE amount in V1. There was a significant difference between the two groups in terms of STE in V3R and presence of small conus branch.17Another study found that STE in aVR, V1, and V3R leads is associated with a small conus that had not reached the interventricular septum. The study examined the relationship between V3R, V1 and aVR during anterior STEMI and the main lesion in LAD and the nature of RCA conus branch. For this purpose, 142 patients with the first MI were enrolled. STE in aVR, V1 and V3R in cases with proximal occlusion to the first septal perforator was more than cases with distal occlusion. Out of the 60 subjects with proximal occlusion, 20 patients had a small conus branch (18 patients with STE in aVR and 15 patients with STE in V1) and 24 patients had a large conus branch . The study revealed that V3R and aVR had a sensitivity of 84% and 90% and specificity of 66.7% and 64.9% in the detection of a small conus branch.Given the important role of the intraventricular septum in patients, there is a need for an appropriate strategy selected for patients presenting with an acute anterior myocardial infarction in order to prevent undesirable consequences. The intraventricular septum can have a double blood supply or a single blood supply from a branch of the LAD artery or conus branch, therefore, the present study tried to compare the relationship between the ECG findings and angiographic findings in patients with acute anterior myocardial infarction.Patients with acute Ant STEMI presenting to the emergency room of Shahid Madani Hospital in the first 12 hours after the onset of symptoms were studied. Patients with devices in their heart, a history of previous myocardial infarction or heart failure, bundle branch block, or chronic renal failure were excluded. Samples were selected by convenient census sampling. All required information was obtained from medical and hospital records of the patients. Written consent was obtained for inclusion in the study from patients’ accompaniment and the study was approved by the Tabriz University Ethics Committee under the number 94/3-9/6. Upon admission, a full 14-lead ECG (including leads V3R and V4R) with a 25 mm/s speed and 1 mV/10 mm standard were performed. Coronary angiography was performed within 48 hours after admission. Coronary angiography was performed for four left coronary system views  and two right coronary system views . The lesion site in LAD artery in relation to the S1 branch and the conus branch type in right coronary artery were identified: small conus branch does not reach the IVS less than 0.5 mm and large conus branch reaches IVS greater than 0.5 mm.The first sample of venous blood was taken within the first hour of patient hospitalization to assess cardiac enzymes and for 2 times every 8 hours repeated to assess the peak levels of enzymes.Clinical heart failure was defined as congestion manifested in chest radiography or presence of bilateral crackles in lung auscultation.Angiographic and ECG findings, clinical heart failure, cardiogenic shock, acute MR, mechanical complications including ventricular septal defect (VSD) and recurrent myocardial infarction (re MI), electrical complications , left and right ventricular LVEF, and mortality were examined. Finally, 74 patients entered the study, the relationship between STE in the right leads and conus size in predicting electrical and mechanical complications, mortality, and ventricular dysfunction was assessed.t test was used to compare quantitative variables. The P < 0.05 value was considered significant.All statistical analyses were performed in SPSS software  using descriptive methods . Normality of the quantitative data was confirmed using the K–S test. Chi-square test (or Fisher’s exact test if needed) were used to compare qualitative results and independent The mean age of the patients was 57.95±12.36 years (median 58 years). The youngest and oldest patients were 32 and 92, respectively. A total of 64 patients (86.5%) were male and 10 patients (13.5%) were female. Positive family history was observed in 3 cases (4.1%), hyperlipidemia in 9 cases (12.2%), hypertension in 25 cases (33.8%), diabetes in 13 cases (17.6%) and smoking in 36 cases (48.6%). The mean interval from onset of pain to the first ECG was 3.43±1.44 hours (median 1 hour). Minimum and maximum durations were 30 minutes and 6 hours, respectively.The infarction site was anteroseptal in 28 cases (37.8%), anterior in 17 cases (23%), and anterolateral in 29 cases (39.2%). Mean STE in V3R and V4R was 1.45±0.73 mm and 0.89±0.36 mm, respectively. Mean STE in aVR and V1 was 0.84±0.24 mm and 1.38±0.76 mm, respectively. Mean total STE in the first ECG was 15.54±8.40 mm. Totally, STE in V3R or V4R was observed in 44 cases (59.5%).Electric complications were observed in 10 cases (13.5%), including VF or VT in the first day in 7 cases (9.5%), VF or VT after the first day, AF and first-degree AV block, each in one case (1.4%).Among mechanical complications, only heart failure was observed in 20 cases (27%).The mean hospital stay was 6.36±4.51 days with a median of 5 days. The minimum and maximum lengths of stay were 2 and 35 days, respectively.In cases with arterial involvement detected in angiography, one-vessel disease was observed in 40 cases (54.1%), and two- and three-vessel disease in 17 cases (23%). LML involvement of over 50% was observed in three cases (4.1%). The lesion site on LAD was proximal in all cases. LCX lesions of over 50% on LCX were observed in 27 cases (36.5%), and on RCA in 24 cases (32.4%). There were 53 cases (73%) of right dominance, 16 cases (21.6%) of left dominance, and 4 cases (5.4%) co-dominance. Small conus was observed in 52 cases (70.3%) and large conus in 22 cases (29.7%).P = 0.44).Totally, electrical complications were observed in 6 patients in the group with small conus branch, and in 4 patients in the group with large conus branch. There was no statistically significant difference between the two groups . There was a statistically significant difference (P = 0.9). No significant difference was observed between small and large conus branch groups in terms of overall death rate (3 cases (5.8%) Vs 0 cases, P = 0.55).In-hospital death was observed in two cases (3.8%) and death during follow-ups was reported in one case (2%) only in the small conus branch group. No cases of death were observed in the large conus branch group. There was no significant difference in this respect between the two groups (P = 0.77).The mean length of hospital stay of patients with large and small conus branch were 6.53±4.99 and 6.86±3.15 days, respectively. There was no significant difference  in the Ethics council of Tabriz University of Medical Sciences.The authors would like to thank all patients participating in this study.


Microorganisms dominate most Antarctic marine ecosystems, in terms of biomass and taxonomic diversity, and play crucial role in ecosystem functioning due to their high metabolic plasticity. Admiralty Bay is the largest bay on King George Island  and a combination of hydro-oceanographic characteristics  create conditions favoring organic carbon deposition on the seafloor and microbial activities. We sampled surface sediments from 15 sites across Admiralty Bay  and the adjacent North Bransfield Basin (693–1147 m), and used the amplicon 454-sequencing of 16S rRNA gene tags to compare the bacterial composition, diversity, and microbial community structure across environmental parameters  between the two areas. Marine sediments had a high abundance of heterotrophic Gammaproteobacteria , followed by Alphaproteobacteria (2.5 and 5.5%), Firmicutes (1.5 and 1.6%), Bacteroidetes (1.1 and 1.7%), Deltaproteobacteria (0.8 and 2.5%) and Actinobacteria (0.7 and 1.3%). Differences in alpha-diversity and bacterial community structure were found between the two areas, reflecting the physical and chemical differences in the sediments, and the organic matter input. Marine microbial communities in sediments play a critical role in ecosystems functioning and are the main drivers of biogeochemical cycling of carbon, nitrogen and sulfur. They constitute a huge biomass portion of the Earth, are highly taxonomic diverse, and responsible for the majority of metabolic activity in the ocean including the polar regions . VariousAs consequences of climate change and rapid warming registered in the Western Antarctic Peninsula, the sea ice declines and glacial inputs increase. These conditions can favor phytoplankton and seaweed blooms , which tAdmiralty Bay is the largest bay on King George Island (South Shetlands Archipelago), located within the maritime Antarctic region. It was designated an Antarctic Specially Managed Area no. 1 (ASMA 1) and contains the Antarctic Specially Protected Area 128 . Its hydrology is complex, as it receives different contributions from water masses originating in the Bransfield Strait, and also from ice melt within the bay . DependiTo understand how the contribution of the organic matter from different sources can shape the microbial community in the Admiralty Bay and surrounding areas, in this study the bacterial diversity and community structure of the sediment samples from Admiralty Bay (AB) and adjacent areas of North Bransfield Basin (NBB) were compared. The results contribute to a better understanding of the sequenced microbial community structure in this polar area, and show differences in richness and community structure between the two sites across physical-chemical characteristics of the sediments.Figure 1). Sampling was conducted by the Brazilian Navy vessel NApOc Ary Rongel during the austral summer, December 2008. In total, 15 samples of marine sediments were collected using a Mini Box Corer (MBC) at different depths. The top 5 cm of sediments were transferred to sterile Whirl-Pack sample bags  and stored frozen onboard (-20°C). Samples were shipped to the University of São Paulo (USP) after 4 months of sampling.Surface sediment samples were collected along a bathymetric gradient in AB – King George Island  and NBB – Bransfield Strait , located in the Northwestern Antarctic Peninsula , following the Wentworth scale , yieldinpfx SuperMix  according to the manufacturer. PCR was performed with a thermal cycler  under the following conditions: 95°C for 5 min, 26 cycles of 95°C for 15 s, 59°C for 30 s and 68°C for 1 min. The PCR products were purified by using a DNA clean & concentrator kit . The amplicons from each sample were mixed at equimolar concentrations and then sequenced using GSFLX titanium instruments and reagents  at the Center for Advanced Technologies in Genomics . All sequence data have been deposited in the National Center for Biotechnology Information Sequence Read Archives (SRA) under BioProject ID PRJNA335729.Genomic DNA was extracted from 0.25 g of surface sediment in quadruplicate using a PowerSoil DNA Kit , according to the manufacturer’s instructions. Microbial 16S rRNA gene fragments were amplified using a set of primers designed by adding a 10-nucleotide barcode to the forward primer, 519F, (5′-CAGCMGCCGCGGTAATWC-3′) and reverse primer 1068R (5′-CTGACGRCRGCCATGC-3′) . The ampt-test in R (version 3.3.2). The amplicon reads were normalized using the package DESeq2 (Raw sequence reads were filtered to eliminate the effect of the random sequencing using the Mothur 454 SOP . The prie DESeq2  followine DESeq2 . Beta-die DESeq2 . To testTable 1). Stations located in the NBB had higher sand contents (6.6–20.6%) when compared to AB samples (0–10.1%), with the exception of station 5 (29.5%), located in front of Lange glacier.Sediments in the area of study were mainly composed of silt and clay (representing 70.4 to 100.0% of sediment composition). In 12 of 15 samples, granulometry was dominated by silt, with the remaining three dominated by clay. The silt fraction in sediments varied from 39.1 to 64.9%, followed by clay (23.1–59.3%) and sand (0–29.5%) (-2 (station 9), and phaeopigment concentrations from 41.68 (station 1) to 84.53 mg.m-2 (station 3), indicating a predominance of degraded organic matter and small quantities of recent organic matter in the sediments. Stations in AB showed higher concentrations of chlorophyll than in the NBB, indicating the presence of higher quantities of recent organic matter to be degraded in the bay. Station 13 presented the highest organic matter concentration (6.0%) and C/N ratio (8.6).The sediment chlorophyll concentrations varied from zero (stations 14 and 15) to 8.25 mg.mIn this study, we used massively parallel signature sequencing technologies to obtain a total of 117,267 sequences (range 1000–26178 reads per sample) from 15 sediment samples from depths varying from 100 to 1.147 m. At the phylum level, all OTUs could be classified and belonged to 22 formally described bacterial phyla and 18 candidate phyla.Figure 2).The abundance analysis showed that eight phyla accounted for more than 97% of the total amplicons: Proteobacteria (89%), Firmicutes (1.5%), Bacteroidetes (1.4%), Actinobacteria (0.9%), Chloroflexi (0.7%), Planctomycetes (0.4%), Verrucomicrobia (0.3%) and Acidobacteria (0.1%)  and Bacteroidetes (0.3–2.2% in AB and 0.6–3.4% in NBB) were also present in all sediment samples at similar rages. Other groups were more abundant in NBB in comparison with AB, such as Deltaproteobacteria (2.5 × 0.7%), Actinobacteria (1.3 × 0.7%) and Cyanobacteria (1.4 × 0.2%).Psychrobacter showed high abundance in all 15 samples, varying from 79.3% (station 15) to 95.4% (station 4). Other nine abundant genera were Psychromonas (0–6.1%), Gillisia (0–4.1%), Loktanella (0–3.9%), Paenisporosarcina (0–2.4%), Bacillariophyta (0–1.8%), Carnobacterium (0–1.4%), Planococcus (0–1.1%), Filomicrobium (0–0.8%) and Blastopirellula (0–0.7%).At the genus level, Table 2). The ACE index used for richness varied from 119.10 (station 1) to 1794.19 (station 11). Simpson’s diversity index varied from 0.40 (station 15) to 0.84 (station 9). Stations 11, 12, 15 and 10 (descending order), located in the NBB, showed the highest richness, and stations 15 and 10 presented the highest diversity. For ACE index, it was verified a significant difference between the two sites .In general, alpha diversity values were higher in NBB when compared to AB. The number of observed OTUs per sample ranged from 36 (station 1) to 417 (station 10) , except for station 9. Stations 2–8 shared more OTUs among each other, with sharing percentages varying from 48.3 to 92.8%. Station 9, placed at the entrance of the bay, shared 7–20 OTUs with stations 1–8, and 41–53 OTUs with stations 10–15, corresponding to 11.7–33.3% and 68.3–88.3%, respectively, and showing as a transitional environment. It was also evident that stations 10–15 shared more OTUs between each other (42.6–88.3%) than with stations inside the bay (3.8–33.3%).When analyzing the shared OTUs, it was found that more OTUs were shared within samples inside the bay r2 = 0.20, p = 0.002). Only station 9, which is a transitional sampling point located at the entrance of the bay, was more related to the second group. Gammaproteobacteria was the dominant taxon for all samples, but others influenced station 10  and station 15 (Deltaproteobacteria and others).To determine the distribution of the bacterial community (beta-diversity), the relative abundance of the different phyla and proteobacterial classes were analyzed in relation to the sampling locations and the sediment physical-chemical parameters using nMDS. It was revealed a clear distinction between samples collected inside AB and in the NBB, where stations 10 and 15 were more distant, which was statistically supported by adonis analysis (r = 0.62), whereas sediments constituted by sand and silt, and higher concentrations of total organic carbon and C/N ratio were predominant outside the bay (NBB), and negatively correlated with nMDS axis 1 (r = -0.98 for both parameters) .The environmental factors associated with the sediment characteristics influenced the samples dissimilarity and the taxonomic composition. Sediments composed by clay, as well as relatively higher concentrations of phaeopigments were prevalent inside the bay and positively correlated with nMDS axis 1 . Additionally, hydro-oceanographic conditions such as bathymetry, regional water circulation and winds regime, continental inputs from glaciers melting, contribution of primary producers, seasonal entrance of water masses, and turbidity, might have favored the organic matter supply in the area. Indeed, a combination of physical and chemical parameters can influence the marine sediment community structure e.g., .The most abundant phylum (Proteobacteria) was represented by the classes Gamma-, Alpha- and Deltaproteobacteria in different proportions between the samples. This supports the results from previous studies showing that this phylum has a wide phylogenetic and phenotypic diversity in several marine and benthic environments . SimilarPsychrobacter as the dominant genus of Gammaproteobacteria in Antarctic sediments has not been previously reported. These heterotrophic versatile microorganisms include piezophilic and halophilic species  and 13 (3.4%), both located in NBB. Several strains have previously been isolated from marine and polar environments, such as Antarctic lakes , may contribute to shape the marine sediment communities in Antarctica.DF, RD, and CS analyzed data and prepared figures and tables. All authors contributed to writing the paper.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.


Older adults living in remote areas with limited access to health services are at higher risk to develop visual impairment and blindness. We conducted a population-based survey to determine the vision status in subjects 45 years of age and older from urban and rural areas of Parintins city, Brazilian Amazon Region. Participants underwent ophthalmic examination, including uncorrected (UCVA), presenting (PVA) and best-corrected visual acuity (BCVA). Vision status was described as lines of visual acuity (VA) impairment and lines of VA improvement from UCVA to BCVA and from PVA to BCVA in the better-seeing eye. A total of 2384 subjects were enumerated, 2041 (85.6%) were examined, with reliable VA measurements obtained from 2025 participants. Vision status in lines of VA impairment was (mean ± standard deviation): 3.44 ± 3.53 for UCVA, 2.85 ± 3.52 for PVA and 1.50 ± 3.51 for BCVA. Female gender, older age and lower education were associated with ≥6 lines of UCVA impairment. Lines of improvement ≥3 was found in 626 (30.9%) participants and associated with female gender and rural residency. In conclusion, a third of participants could have at least three lines of VA improvement with proper refraction. Strategies to improve access to eye care and affordable glasses are needed. Most studies detail only the visual acuity levels of those blind or visually impaired, and little is known on the visual status of those considered with “normal” vision2. The distribution of visual acuity and impairment are of intrinsic value in defining the vision status of a population3.The magnitude and burden of visual impairment (VI) and blindness usually are estimated through population-based epidemiological studies based on visual acuity cut-off criteria using either best-corrected or presenting distance visual acuity (VA)5, but most studies do not report uncorrected VA. A more detailed analysis across the entire visual acuity range from 20/20 to no light perception could lead to a better understanding of the vision status of specific populations, and advocate for medical interventions in those at risk of developing visual impairment in the future.Over the last decade there was a shift between the use of “best corrected” to a current use of “presenting” distance visual acuity  for blindness6. The city of Parintins with a 2010 census population of 102,718, is fairly representative in sociodemographic terms of the population of the Brazilian Amazon Region population.  Adults 45 years or older were 17.1% of the population in Parintins city (Census 2010) and 24% in the BARES sample with 44.7% of these male vs 44.9% throughout urban areas of the Brazilian Amazon Region. Literacy is 89.8% in Parintins, compared to 89.7% for the Brazilian Amazon Region. Our objective was to describe the vision status and improvement from uncorrected and presenting vision status to best-corrected vision status in urban and rural populations from the Brazilian Amazon.The present data come from a recent population-based survey of visual impairment and blindness among adults in the city of Parintins located in the Brazilian Amazon Region (BARES)5. In defining sampling frame clusters, census sectors with fewer than 70 persons 45 years of age or older were grouped with an adjacent sector and sectors with more than 140 persons 45 years of age or older were segmented, producing 154 clusters with 70 to 140 persons 45 years of age or older.BARES is a population-based, cross-sectional epidemiological study designed to examine the prevalence and causes of vision impairment and blindness in a noninstitutionalized, population-based sample of older Brazilian Amazonians. Parintins is a 102,000 inhabitants city located at 02°37’42”S and 56°44′09″W, in the center of the Brazilian Amazon Region on the sides of the Amazon River, with hot and humid tropical climate. It can be reached by air (300 km) and about 420 km by boat from Manaus. The study population consisted of residents 45 years or older, living in 20 randomly selected clusters  in Parintins city. The study population was selected through cluster sampling based on 2010 Census data12–15. Assuming an examination response rate of 85%, allowing for an arbitrary 50% increase in sample size to accommodate possible inefficiencies associated with the cluster sampling design, and adjusting for the finite population factor, a sample size of 1393, with an increase to 2459 persons 45 years or older was required. Accordingly, 20 clusters , consisting of 18 census sectors, were randomly selected with equal probability from the 154 sampling units. Further details on sampling plan, and baseline demographic data have been reported elsewhere6. In brief, a door-to-door enumeration was performed and eligible subjects were informed about the study and invited to participate in a clinical ophthalmic examination.Sample size requirements were calculated on the basis of estimating an expected blindness prevalence of 6%  within an error bound (precision) of 20% with 95% confidence intervalThe institutional review board/ethics committees both from Universidade Federal de São Paulo (UNIFESP) and from Universidade Federal do Amazonas (UFAM) approved the study protocol. The study was carried out in accordance to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants after explanation of the nature and possible consequences of the study.7, including VA testing, which was performed in a standardized manner at the local eye clinic for urban participants and at an itinerant eye examination center for those living in rural clusters6. In-home eye exam was offered for those who could not come to the clinic and it was performed with portable equipment.The enumeration form included household address, phone number, and a roster of those living in that home along with their gender, age and schooling. All eligible individuals (adults 45 years of age and older) were invited and scheduled for a detailed eye examination. Written informed consent was obtained at the examination site, followed by VA measurements for distance, refraction, and an eye examination. The examination protocol was similar to the one used in SPES7. During the enumeration process participants were asked about spectacle usage and advised to bring their glasses to the eye exam. Glasses were cleaned before visual acuity measurement when needed. Best-corrected visual acuity (BCVA) was determined for each eye after auto-refraction followed by subjective refraction performed by an ophthalmologist.Ophthalmic technologists measured from each eye presenting distance visual acuity (PVA), with spectacles if the participant presented with them followed by uncorrected distance visual acuity (UCVA), using retro-illuminated logarithm of the minimum angle of resolution tumbling E charts at 4 m distance. Details about visual acuity measurement procedure can be found elsewhereVision status was defined for each eye by lines of vision impairment on the ETDRS chart from 0 to 16, with the number increasing as VA deteriorated. Accordingly, VAs of 20/20, 20/25, 20/32 and 20/40 were represented by line numbers 0, 1, 2 and 3, respectively. VA of 20/200 was represented by line number 10, with line 11 corresponding to VA of 20/250; line 12 corresponding to VA of 20/320; line 13 corresponding to VA of 20/400; line 14 to VA of 20/500; line 15 to VA of 20/640 and line 16 to VA ≤ 20/800.Improvement in lines of vision impairment was calculated for each eye as the UCVA line number minus the line number at BCVA; thus, a positive line change indicated an improvement of vision between UCVA and BCVA and a negative change indicated worsening of vision between UCVA and BCVA.Visual acuity measurements were categorized as: normal vision, ≥20/32; near-normal vision , <20/32 to ≥20/63; visual impairment, <20/63 to ≥20/200; moderate blindness, <20/200 to ≥20/400; and severe blindness, <20/400. Those with 20/20 vision in both eyes were noted.8. Confidence intervals (CI) for prevalence estimates and regression odds ratios (OR) were calculated taking cluster sampling design effects into account. P values ≤ 0.05 were considered statistically significant.Multiple logistic regression was used to investigate the association of categories of age , gender, categories of schooling  and urban/rural residence with participation in the study and with vision impairment. Statistical analyses were performed using Stata/SE Statistical Software, Release 14.0, 2015 The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.6. Reliable visual acuity measurements in both eyes were obtained from 2025 participants. Table During the period from March 2014 to May 2015, a total of 2041 participants were recruited and completed an eye examination. Of the 9931 residents, 2384 (24.0%) were eligible (aged 45 years and older) for BARES. Of these, 8 (0.3%) refused to participate, 335 (14.1%) did not show up for the clinical examination, and 2041 completed an ophthalmic examination, resulting in a participation rate of 85.6% (2041/2384). Demographic characteristics of the study population were described in detail previouslyIn the 2025 participants with reliable VA, 1293 (63.4%) presented without glasses; glasses for distance only were used by 23 (1.1%) participants; glasses for both near and distance were used by 480 (23.7%) participants; and glasses for near only were used by 229 (11.3%) participants.Overall, lines of VA impairment in the better-seeing eye N = 2025) was (mean ± standard deviation): 3.44 ± 3.53 with UCVA, 2.85 ± 3.52 with PVA and 1.50 ± 3.51 with BCVA. The prevalence of 6 or more lines of uncorrected vision impairment was 21.6% (95% CI: 19.8 to 23.4); 17.0% (95% CI: 14.8 to 19.2) for presenting vision impairment and 7.3% (95% CI: 6.1 to 8.5) for best-corrected vision impairment. In multiple logistic regression modeling, 6 or more lines of vision impairment was associated with older age for uncorrected, presenting and best-corrected vision in the better-seeing eye  was found in 49.9% [95% Confidence Interval (CI): 47.1–52.8] of the sample increasing to 60.6% [95% CI: 57.7–63.5] for presenting VA and to 81.4% [95%CI: 79.3–83.4] for best-corrected VA. The prevalence of uncorrected mild visual impairment (20/40 to 20/63) in the better-seeing eye was 28.4% [95% CI: 26.7–30.3]; 22.3%  with best correction. The prevalence of uncorrected visual impairment (<20/63 to 20/200) was 17.2% [95% CI: 14.29–19.8]; 12.8% [95% CI: 10.8–15.2] for presenting VA and 4.1% [95% CI: 2.9–5.7) with best correction. The prevalence of uncorrected moderate blindness (<20/200 to 20/400) in the better-vision eye was 1.58% [95% CI: 1.15–2.17]; 1.38% [95% CI: 1.04–1.84] for presenting VA and 0.54% [95% CI: 0.31–0.94) with best correction. The prevalence of uncorrected severe blindness (worse than 20/400) in the better-seeing eye was 2.86% [95% CI: 2.34–3.50]; 2.81% [95% CI: 2.30–3.44] for presenting VA and 2.67% [95% CI: 2.18–3.25) with best correction. These results are presented in Fig. Table The lines of improvement with BCVA compared to UCVA ranged from 0 to 11 lines (mean = 1.94 ± 2.06); and ranged from 0 to 9 lines (mean = 1.36 ± 1.91) with BCVA compared to PVA. Improvement of three or more lines in UCVA with BCVA was found in 626 (30.9%) participants, and in 399 (19.7%) participants.In 615 (30.4%) participants there was no change in VA in the better-seeing eye with BCVA, including 406 (20.0%) participants with 20/20 UCVA, 48 (2.4%) participants with 20/25 vision, 22 (1.1%) participants with 20/32 vision along with another 139 (6.9%) participants having visual impairment ≤20/40 .The change in lines in the better-seeing eye from UCVA to BCVA is shown in Fig. The association of VA improvement of three or more lines with BCVA in the better-seeing eye was investigated with multiple logistic regression with gender, age, schooling, and residence as co-variates. Female gender  and rural residency  were significantly associated with three or more lines of improvement from UCVA to BCVA in the better-seeing eye.The strengths of this study were the large, randomly selected sample of participants and the fact that refraction was performed in all participants along with measurement of uncorrected, presenting (with glasses if they were used) and best-corrected (after subjective refraction) visual acuity from each eye under controlled conditions. To improve reliability and precision of visual acuity scores, clear instructions were given during the enumeration process for the participants to bring their own glasses to the examination station. The limitations to perform this survey were: (a) the distance and costly access to the city of Parintins; (b) the fact that the whole survey had to be executed during only four visits to maximize the permanence of the study team, the transport of equipment and availability of infrastructure for the ophthalmic exam and (c) the need to use a large boat to accommodate study team and equipment for 18 consecutive days to achieve the goal of testing residents in rural areas.9. Possible explanations for these findings take into account that women are more concerned about their healthcare than men, that older subjects have increased need for eye care services, that those with higher instruction have awareness of the importance of health care and that those in rural areas are in need due to lack of access. An additional observation related to the lack of access was that approximately only one third of the participants were wearing glasses, whereas in a similar study performed in Sao Paulo city 10 years earlier 51% participants were wearing glasses with distance correction7. Once again female gender and higher education were associated to any glasses usage. The fact that in Parintins city there was only one ophthalmologist residing in the city during the study period could explain partially these results. Consequently, refractive services were limited and available only to those who could afford to pay for a pair of glasses. To note, the urban areas of Parintins are not directly comparable to urban areas of a previous population-based study performed by our group in the city of São Paulo, the largest city in South America. In that sense, a more realistic classification for urban Parintins would be to consider it as semi-rural instead of urban.After adjusting for differences in age, gender, education and residency area, females, those with age between 65–74 years, those with higher education and those living in rural areas were more prone to come to the eye examination. These results are in line with previous studies in developing countries where female gender, older age and higher education were associated with participation in the eye exam10. In 45 (2.2%) participants the better-seeing eye switched from UCVA to PVA, in 89 (4.4%) from PVA to BCVA and in 109 (5.4%) participants from UCVA to BCVA. These changes can be explained by differences in the magnitude of refractive error between eyes, inadequate optical correction in only one eye or presence of eye diseases considered optically uncorrectable as incipient cataract.The importance of including uncorrected visual acuity measurement in the study protocol is that uncorrected vision reflects a biological score of vision status, with presenting vision reflecting the services provided (since it was measured with glasses in 25% of participants) and best-corrected vision showing the optimal vision status to be reached with standard ophthalmic care. Vision status considering lines of visual impairment decreased approximately 50% both from uncorrected and presenting to best-corrected distance visual acuity. The decrease in vision impairment can also be confirmed by the results comparing uncorrected, presenting and best-corrected vision except to the severe blindness category in which similar results among the three measurements were found. These findings reinforce the strong impact of refractive services in this population with limited access to eye care providers. It is also remarkable that only 10% of the participants could reach 20/20 vision in both eyes with uncorrected visual acuity, with improvement to almost half of the sample considering the best-corrected vision. Sometimes, the worse-seeing eye with UCVA and with PVA may become the better-seeing eye after refraction, so that it is important to refract both eyesThe availability of data from two ppulation-based studies performed in the last decade into two distinct socio-demographic areas: a low-income area of São Paulo city (SPES), the most industrialized city in the country along with urban and rural areas of Parintins city (BARES), in the central location of the Brazilian Amazon Region, allows comparisons that reflect regional and socio-economic disparities in the country. Even though SPES was performed 10 years earlier and in a population 5-years older than BARES population, the distribution of vision status categories between these two Brazilian studies using the same protocol are remarkable. Presenting normal vision (≥20/32) in the better-seeing eye was found in 78.1% in SPES and in 60.6% in BARES, increasing to 91.5% with best optical correction in SPES and to 81.4% in BARES. On the other hand, the prevalence of presenting severe blindness (<20/400) in the better-seeing eye was 0.77% in SPES and 2.81% in BARES, decreasing to 0.55% with best correction in SPES and to 2.67% in BARES. The fact that 2.67% remain blind despite the best optical correction is probably related to a substantial number of persons with irreversible blindness or with unoperated severe cataract. The inequalities of access to eye care services are substantial with people living in remote areas showing a five-fold prevalence of severe blindness than those living in low-income areas of developed cities.13. In the Australian study the change from visual impairment with PVA (<20/40 in the better-vision eye) to no visual impairment with BCVA (≥20/40 in the better vision eye) was found in 7.5% participants 49 years of age and older11. In Mexican-Americans 40 years and older, 6.0% had changed from visual impairment to no visual impairment with refractive correction12. In the Taiwanese study, 9.6% of participants (65 years of age and older) changed from visual impairment with PVA to no visual impairment with BCVA13. Applying this criterium to our data, 19.7% participants had optically correctable visual impairment. This finding might be related to the restricted access to refractive services in that remote part of Brazil.Other population-based studies have showed optically correctable visual impairment in older adults using distinct criteria12 and in the clinic to evaluate a large sample of patients with low vision10. In Mexican-Americans from Proyecto VER, out of 390 (8.2%) participants with visual impairment (PVA < 20/40 in the better-vision eye) a change in 2 or more lines from presenting to best-corrected vision was found in 299 (77%)12. In the current study, out of 604 (29.8%) participants with visual impairment (PVA < 20/40 in the better-vision eye), a change of 2 or more lines from PVA to BCVA was found in 398 (66%).The analysis of change in lines from presenting to best-corrected vision had been used in population-based studiesThe current results demonstrate that around a third of the older adults from Parintins, Brazilian Amazon Region, obtained at least three lines of improvement in their visual acuity with proper refraction and approximately 20% of participants had optically correctable visual impairment. Sociodemographic parameters as female gender and rural residency were associated with three or more lines of visual acuity improvement by refraction. Based on these findings, it is important to reinforce to health authorities the need of sustainable actions to improve access to ophthalmic care along with provision of affordable glasses. The importance of regular eye examination and the possibility of improving visual acuity by wearing glasses should be improved to this population.