Liver stiffness measurement (LSM) by transient elastography  is a validated method for noninvasively staging liver fibrosis. Most hepatic complications occur in patients with advanced fibrosis. Our objective was to determine the ability of LSM by TE to predict hepatic complications and mortality in a large cohort of patients with chronic liver disease.In consecutive adults who underwent LSM by TE between July 2008 and June 2011, we used Cox regression to determine the independent association between liver stiffness and death or hepatic complications . The performance of LSM to predict complications was determined using the c-statistic.P<0.00005). The 2-year incidence rates of death or hepatic complications were 2.6%, 9%, 19%, and 34% in patients with liver stiffness <10, 10–19.9, 20–39.9, and ≥40 kPa, respectively (P<0.00005). After adjustment for potential confounders, liver stiffness by TE was an independent predictor of complications . The c-statistic of liver-stiffness for predicting complications was 0.80 (95% CI 0.75–0.85). A liver stiffness below 20 kPa effectively excluded complications ; however, the positive predictive value of higher results was sub-optimal (20%).Among 2,052 patients , 87 patients (4.2%) died or developed a hepatic complication during a median follow-up period of 15.6 months . Patients with complications had higher median liver stiffness than those without complications (13.5 vs. 6.0 kPa; Liver stiffness by TE accurately predicts the risk of death or hepatic complications in patients with chronic liver disease. TE may facilitate the estimation of prognosis and guide management of these patients. Liver fibrosis assessment is a vital aspect of the management of patients with chronic liver disease, both for guiding therapy and estimating prognosis. Most hepatic complications occur in patients with advanced fibrosis. Although liver biopsy had traditionally been used to stage fibrosis, it is limited by invasiveness, potential complications, cost, and difficulty of repetition for monitoring changes over time et al. reported that LSM by TE had superior diagnostic performance for predicting 5-year survival compared with biopsy TE is an ultrasound-based tool for measuring liver stiffness as a surrogate of fibrosis that is widely used due to its high accuracy for the diagnosis of advanced fibrosis The objective of our study was to examine the association between liver stiffness and the risk of death or liver-related complications in a large cohort of patients with diverse hepatic disorders and severities to reflect routine clinical practice. We report risk estimates at clinically relevant liver stiffness thresholds that that may help physicians estimate the prognosis of their patients and guide their management.This retrospective-prospective study included consecutive adults (≥18 years) with chronic liver disease  who underwent LSM by TE at the University of Calgary Liver Unit (UCLU) between July 2008 and June 2011. The UCLU is the major referral center for patients with liver disease in southern Alberta serving a catchment population of ∼1.5 million individuals. LSM by TE is performed routinely in all UCLU patients without overt evidence of hepatic decompensation. Patients with any of the following criteria were excluded: 1) non-residents of Alberta; 2) invalid provincial health numbers and/or the inability to link clinical information with administrative data (see below); 3) liver-related complications prior to or at the time of their FibroScan (see below); and 4) FibroScan failure, defined as no valid LSMs after ≥10 attempts. The Research Ethics Board at the University of Calgary approved the study protocol. The requirement for individual informed consent was waived for the study; however, patient records were anonymized and de-identified prior to analysis.2). Briefly, with the patient lying in the dorsal decubitus position and the right arm in maximal abduction, the tip of the FibroScan transducer probe was placed on the skin between the ribs over the right lobe of the liver. Assisted by a sonographic image, a portion of the liver ≥6 cm thick and free of large vascular structures was identified and an attempt was made to collect ≥10 valid LSMs. The median liver stiffness value was considered representative of the elastic modulus of the liver. Fasting prior to the examination was not routinely required. As an indicator of variability, the ratio of the interquartile range (IQR) of liver stiffness to the median (IQR/M) was calculated. As recommended by Boursier and colleagues Two experienced operators performed all FibroScan examinations as per the manufacturer’s recommendations. Between July 2008 and July 2009, the M probe was used in all patients; thereafter, the XL probe was used in obese patients  Tenth Revision of the ICD (ICD-10) Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures (CCP)Canadian Classification of Health InterventionsPatients were managed as per consensus recommendations and followed according to the discretion of their hepatologist. Our primary outcome measure was a composite that included overall mortality and hepatic complications, including features of decompensation , HCC, and liver transplantation. Complications were identified by querying the administrative databases for relevant diagnosis and procedure codes according to the a priori examined these comorbidities individually and the remainder were categorized . We also examined the type of FibroScan probe because the XL probe gives lower readings than the M probe The primary predictor variable was median liver stiffness examined as a continuous variable; according to established cut-offs : 9.5–12.4 kPa; and F4 (cirrhosis): ≥12.5 kPa) P-values <0.05 were considered statistically significant. The association between liver stiffness and hepatic complications or mortality was assessed using the Kaplan-Meier method and Cox proportional hazards regression All analyses were performed using Stata v11.0 . Between groups comparisons were made using Fisher’s exact, chi-square, and Mann-Whitney tests, as appropriate. Two-sided To assess the performance of LSM by TE in predicting death or hepatic complications during follow-up, we calculated the sensitivity, specificity, accuracy, and positive (PPV) and negative predictive values (NPV) of a threshold of ≥20 kPa. Previous studies have shown that this threshold reliably excludes hepatic complications during medium-term follow-up et al.In total, 2,437 patients had a LSM by TE during the study period. After excluding 385 ineligible patients, 2,052 were included in the study cohort . The medP<0.00005). Of the 124 total complications, specific events are outlined in During a median follow-up period of 15.6 months (IQR 11.0–23.5), 87 patients (4.2%) died or developed a hepatic complication, corresponding to an overall incidence of 2.8 cases per 100 person-years . In the subpopulation of 315 patients with presumed cirrhosis, 46 cases (14.6%) developed a complication, corresponding to an overall incidence of 10.1 (95% CI 7.5–13.4) per 100 person-years . In patients with liver stiffness <10, 10–19.9, 20–39.9, and ≥40 kPa, actuarial rates of death or hepatic complications at 1, 2 and 3 years were 1.3% (95% CI 0.8–2.0%), 2.6% (1.7–4.0%) and 3.9% (2.2–6.7%); 6.6% (4.1–10.4%), 8.8% (5.6–13.6%) and 10% (6.4–15.6%); 14% (9.4–22%), 19% (12–28%) and 19% (12–28%); and 29% (18–44%), 34% (21–52%) and 34% (21–52%), respectively (P<0.00005).Patients who died or developed a hepatic complication during follow-up had higher median liver stiffness than patients without complications . For the secondary outcomes of hepatic decompensation or HCC (n = 76) and overall mortality (n = 17), the c-statistics of liver stiffness were 0.82 (95% CI 0.77–0.87) and 0.67 (0.55–0.80), respectively.The c-statistic of liver-stiffness for the prediction of hepatic complications and mortality was 0.80 (95% CI 0.75–0.85). The sensitivity, specificity, PPV, NPV, and accuracy of a liver stiffness value ≥20 kPa for predicting complications were 41% (95% CI 31–52%), 93% (91–94%), 20% (14–26%), 97% (96–98%), and 90% (89–92%), respectively. The actuarial rates of death or hepatic complications at 3 years in patients with liver stiffness ≥20 kPa and <20 kPa were 23% (95% CI 16–30%) and 4.7% (3.2–7.0%), respectively  Our study has several limitations. First, our findings rely on the validity of the administrative databases that we used. Although chart abstraction studies have confirmed their accuracy for many hepatic In conclusion, liver stiffness measured by TE is an independent predictor of hepatic complications and mortality in patients with chronic liver disease. The risk estimates that we report at clinically relevant liver stiffness cut-offs will provide valuable information to physicians and assist them in counseling their patients regarding their prognosis and may help guide their follow-up.Appendix S1Diagnosis and procedure codes used to define hepatic diagnoses and hepatic complications.(DOCX)Click here for additional data file.


Incidence and case-fatality ratios are higher for non–type b than for type b infection. Haemophilus influenzae type b (Hib) vaccination on invasive H. influenzae disease; 14 countries routinely serotype all clinical isolates. Of the 10,081 invasive H. influenzae infections reported during 1996–2006, 4,466  were due to noncapsulated H. influenzae (ncHi); 2,836 , to Hib; and 690 , to non–b encapsulated H. influenzae. Invasive ncHi infections occurred in older persons more often than Hib  and were associated with higher case-fatality ratios , particularly in infants . Among non-b encapsulated H. influenzae, types f (72%) and e (21%) were responsible for almost all cases; the overall case-fatality rate was 9%. Thus, the incidence of invasive non–type b H. influenzae is now higher than that of Hib and is associated with higher case fatality.An international collaboration was established in 1996 to monitor the impact of routine  Haemophilus influenzae is differentiated according to its capsular polysaccharide composition into 6 serotypes (a–f) and noncapsulated strains (H. influenzae type b (Hib) caused >80% of invasive H. influenzae infections, primarily in healthy children <5 years of age  and expanded to include more countries; by 2006, a total of 28 countries routinely reported cases to EU-IBIS (www.euibis.org). Participating countries reported cases of invasive H. influenzae disease to a central database, with basic demographic details, clinical syndrome, outcome, specimen site, and serotyping data on isolates. The UK Health Protection Agency Haemophilus Reference Unit (HRU) coordinated development of standardized laboratory protocols for growing, serotyping, and PCR genotyping H. influenzae and exchange of clinical isolates to ensure consistency of results. HRU also provided genotypic confirmation of serotypes for countries without established reference facilities and regularly distributed quality assurance strains to participating laboratories to ensure comparability of results. Annual reports were made available to participants at meetings and on the EU-IBIS website.A 3-year European Union–funded study (the BIOMED II Hib surveillance project) was initiated in 1996 to study the epidemiology of invasive H. influenzae disease was defined as isolation of the organism from a normally sterile site. A case of meningitis was defined as H. influenzae cultured from cerebrospinal fluid or clinical and/or radiologic features of meningitis with blood culture positive for H. influenzae. Other clinical presentations, including epiglottitis, pneumonia, cellulitis, and osteomyelitis, were defined as isolation of H. influenzae from a normally sterile site  in a person with clinical signs and symptoms consistent with that presentation. Bacteremia was defined as growth of H. influenzae from blood cultures only, with no distinctive clinical syndrome identified.Invasive www.euibis.org. Germany and Israel reported data for children only and were included in some of the analyses. Within the United Kingdom, data from England and Wales were collected separately from Scotland because the surveillance program in England and Wales is separate from that in Scotland. In Greece, during 1996–2002, surveillance was limited to a single prefecture, Attiki, and provided data only for persons <15 years of age; after 2002, national data were available for Greece. Italy initially relied solely on laboratory reporting with voluntary notification of confirmed cases of meningitis, but a more active laboratory-based surveillance system was established in 8 Italian regions in 1997–1998 , 7 regions in 1999–2002 (Lombardia was no longer included), and nationally thereafter. All data were collected as part of enhanced national surveillance and rendered anonymous at the source.This study included only countries that routinely vaccinated children against Hib before 2000 and serotyped at least 50% of all clinical isolates. Detailed surveillance methods for all participating countries are available at www.stata.com). Total and age-grouped population estimates used as denominators for incidence calculations were obtained either from the national statistics website of the relevant country or from EU-IBIS participants  by using the number of reported deaths as the numerator and all cases, including those for which outcome was not reported, as the denominator. We calculated age-adjusted odds ratios (ORs) for noncapsulated H. influenzae (ncHi) and Hib using logistic regression; we inclulded age and serotype  as independent variables. Ages are given as medians and interquartile ranges (IQRs) and compared by using the Mann-Whitney U test. Proportions were compared by using the χ2 test or Fisher exact test; continuous variables were compared by using Student t tests.Data were entered by using Microsoft Excel , and statistical analysis was performed by using Stata 8.0  were Hib, 690 (7.8%) were other capsulated H. influenzae, and 4,466 (44.3%) were ncHi. For 125 (1.2%) cases, the isolates were identified as non–type b, but complete serotyping was not performed. Capsular serotype was not available for 1,964 (19.5%) isolates, mainly because the isolate was not available for typing at the reference laboratory . The crude overall annual incidence rates for invasive Hib, ncHi, and non–type b encapsulated H. influenzae infections were 0.15, 0.28, and 0.036 cases per 100,000 population .During 1996–2006, a total of 14 countries reported 10,081 invasive pulation . After aH. influenzae cases occurred, including 2,005 (27.8%) Hib and 3,172 (44.0%) ncHi cases. Patient sex did not differ for Hib and ncHi infections . However, a higher proportion of women in the 25–44-year age group developed invasive ncHi infection: 117/165 (70.9%) for those 25–34 years of age and 93/166 (56.0%) for those 35–44 years of age, compared with 1,310/2,785 (47.0%) for the other age groups. Women 25–44 years of age who had invasive ncHi infection also were more likely than men in the same age group to have bacteremia . For Hib, sex was not associated with clinical presentation for persons in any age group.After 2000, when all countries included in the study had implemented the Hib vaccine into their national immunization programs, 7,211 2 = 438; p<0.0001). By contrast, only 13.7% of Hib cases occurred in persons >65 years of age, compared with 42.7% of ncHi . The most common clinical diagnosis was bacteremia for both Hib and ncHi, but the median age of persons with Hib bacteremia was much lower than for that for those with ncHi bacteremia  years, p<0.0001) . More thcteremia . Hib men2 = 11.6; p = 0.001); 112/148 (75.7%) of ncHi case-patients in the first week of life had bacteremia, compared with 50.0% (17/34) of those in whom ncHi occurred at 7–30 days of life . Infections from ncHi in infants decreased after the first month of life and remained fairly constant during the first year . In the first month, ncHi cases were more likely to occur in the first week (148/182 [81.3%]) compared with Hib  of the 7,211 persons with  infants . For botH. influenzae were rare. Cases did not cluster by country or time, and individual serotypes or incidence, either overall or in any single country, did not increase during the 11-year study period. Of the 690 cases, Hif was the most prevalent subtype (500 [72.5%] patients) followed by Hie (143 [20.7%]) (>65 years of age (17/72 [23.6%]); however, none of the 22 children <16 years of age who had Hie infection died. Compared with Hif, the age-adjusted OR for death from Hie was 2.0 . All 3 Hia-related fatalities occurred in children <2 years who had meningitis.Invasive infections caused by non–type b encapsulated [20.7%]) . The oveH. influenzae varied with age. A total of 140  occurred in children <5 years of age. In this age group, meningitis (61 [43.6%] patients) was the most common clinical presentation and was caused by Hif (49 patients [80.3%]), Hie (7 patients [11.5%]), and Hia (5 patients [8.2%]). Children <5 years of age were more likely to have meningitis than were older children and adults . Two thirds of Hia infections (17/26 [65.4%] patients) occurred in children <5 years of age, compared with 21.2% (106/500) of Hif, 9.8% (14/143) of Hie, and 33.3% of Hic (3/9). Persons in this age group with either Hif  or Hie  infections were more likely to have meningitis, whereas older children and adults were more likely to have bacteremia and pneumonia. The CFR for children <5 years of age was lower than that for older children and adults .The epidemiology of non–type b encapsulated H. influenzae infections among the 247 persons 5–64 years of age resulted mainly from Hif (17 [69.2%]) and Hie (57 [23.1%]). Most Hic (5/9 [55.6%]) and Hid (10/12 [83.3%]) infections also occurred in this age group. All serotypes were responsible for the 45 meningitis cases: Hif (26 [57.8%]), Hie (12 [26.7%]), Hid (4 [8.9%]), Hic (2 [4.4%]), and Hia (1 case [2.2%]). The CFR for this age group was 7.3% (18/247 patients), but no persons with meningitis died, compared with 12.0% (9/75 patients) and 11.5% (6/52 patients) of those with bacteremia and pneumonia, respectively.Non–type b encapsulated >65 years of age; Hif (221/301 [73.4%]) and Hie (72/301 [23.9%]) accounted for almost all cases. The overall CFR was highest for this age group (39/301 [13.0%] patients) and similar for those with bacteremia (17/102 [16.7%]), pneumonia (9/59 [15.3%]), or meningitis (2/14 [14.3%]). The CFR for Hie was 23.6% (17/72 patients), compared with 10.0% (22/221) for Hif  for persons >65 years of age.Almost half the cases (301 [43.6%]) occurred among persons H. influenzae serotypes, ncHi, or other respiratory pathogens might fill the ecologic niche. However, little evidence exists for a substantial or sustained increase in invasive non–type b H. influenzae infections  of 7 Hic, and 4 (67%) of 6 Hid cases occurred in persons 18–64 years of age (Infections caused by Hic and Hid are rare and have low CFRs, suggesting that they may not be particularly virulent. There is a paucity of information on infections caused by these serotypes, even in the form of individual case reports. Our data suggest that these invasive Hic and Hid infections are more common in adults. A recent US study reported that, of 770 cases of invasive H. influenzae were significantly higher than for Hib. The CFRs in our study should be considered a minimum because we cannot be sure that all deaths would be reported to the surveillance systems, particularly if death occurred a considerable time after infection. Other studies with more active follow-up in adults with ncHi infections have reported CFRs of 13%–20% (H. influenzae infections was also higher than for Hib and comparable to the 15%–30% reported in other studies (That CFR from invasive Hib disease remains low and similar to that reported in other industrialized countries is reassuring, even though it has not changed substantially from the prevaccine era ( studies  most likH. influenzae infections across all age groups to assess the long-term effectiveness of Hib vaccination, rapidly detect unexpected population effects and potential changes in circulating strains, and monitor changes in the epidemiology of invasive H. influenzae disease. Further studies are needed to define more clearly host and pathogen risk factors for invasive H. influenzae infection and factors associated with death.Thus, despite the reduction in Hib disease, continued surveillance is needed for all


Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae) require a carbohydrate source from plant or other exudates and nectars for dispersal and reproduction. Adults actively seek and forage at feeding sites upon eclosion in the habitat of the larval host plant or during dispersal to, or colonization of, a suitable reproductive habitat. This nocturnal behavior of H. zea has potential for exploitation as a pest management strategy for suppression using an adult feeding approach. This approach entails the use of a feeding attractant and stimulant in combination with a toxicant that when ingested by the adult will either reduce fecundity/fertility at sub-lethal dosages or kill the adult. The intent of this study was to assess reproductive inhibition and toxicity of emamectin benzoate on H. zea when ingested by the adults when mixed in ppm active ingredient (wt:vol) with 2.5 M sucrose as a feeding stimulant. Because the mixture has to be ingested to function, the effect of emamectin benzoate was also evaluated at sub-lethal and lethal concentrations on proboscis extension and gustatory response of H. zea in the laboratory. Feral males captured in sex pheromone-baited traps in the field were used for toxicity evaluations because they were readily available and were more representative of the field populations than laboratory-reared adults. Laboratory-reared female moths were used for reproduction effects because it is very difficult to collect newly emerged feral females from the field. Emamectin benzoate was highly toxic to feral H. zea males with LC50 values (95% CL) being 0.718 (0.532–0.878), 0.525 (0.316–0.751), and 0.182 (0.06–0.294) ppm for 24, 48 and 72 h responses, respectively. Sub-lethal concentrations of emamectin benzoate did not significantly reduce proboscis extension response of feral males and gustatory response of female H. zea. Sublethal concentrations of emamectin benzoate significantly reduced percent larval hatch of eggs and mating frequency of female H. zea. Larval survival to the pupal stage was also significantly reduced by ingestion of emamectin benzoate by female H. zea. These data suggest that emamectin benzoate is a useful toxicant in an attract-and-kill control strategy against H. zea. Field studies are warranted to validate the results reported in this study.Newly emerged corn earworm adults,  The concept of using feeding attractants and stimulants in combination with a toxicant for adult control of noctuid pest has been documented . The feeHelicoverpa zea (Boddie) (Lepidoptera: Noctuidae), and its closely related species, the tobacco budworm, Heliothis virescens, occur throughout the temperate and tropical regions in the Americas . Jansson and Dybas  larvae.Emamectin benzoate belongs to the avermectin group of chemicals produced by the soil-dwelling actinomycete (NRRL 8165) alias,   growing near their emergence habitat.An appreciation of nocturnal activity of n et al.  studied n et al.  also deme et al.  found laH. zea was examined relative to toxicity, proboscis extension, gustatory response, reproduction, and survival of the progeny when it was provided in a feeding stimulant solution to the adult insect.A major drawback to the development of “attract-and-kill” strategy is the lack of fundamental information vis-à-vis toxicants and their effects on the target insect. In this study, the effect of emamectin benzoate against Feral males. Natural populations of males were chosen to study lethal concentration, proboscis extension response and mean lethal time because feral males are readily available throughout the growing season through captures in pheromone-baited traps. Pheromone traps were established using 75–50 Texas wire cone sex pheromone traps (www.herconenviron.com). The wire cone measured 75 cm in diameter reduced to a 50 cm opening for moth's entry at the bottom of the cone. The traps were established in close proximity to cotton fields in the Brazos River Valley near College Station, TX, and were serviced every morning. Before the tests were conducted, males captured in the morning were fed deionized water through water-soaked sanitary pads.ne traps  baited wLaboratory-reared moths. H. zeas were reared in the laboratory from eggs obtained from the Southern Insect Management Laboratory, USDA-ARS, Stoneville, MS., using similar techniques described previously (www.wardsci.com). Approximately 4 g of the diet was dispensed into a plastic soufflé cup using a caulking gun and an individual larva was placed on the diet and sealed with a lid. About 3 weeks thereafter, pupae were harvested, sorted by sex, and male and female pupae were placed separately in 3.78 L jars for moth emergence. All rearing and testing with lab oratory-reared moths were conducted during the day in a laboratory maintained at 23.9 ± 0.38°C, RH 64.5 ± 4.6 % and a photoperiod of 14:10 L:D.eviously . Larvae www.syngentacropprotection.com) wasprepared in deionized water. Serial dilutions ranging from 0.0125 to 200 ppm were then prepared by dilution with 2.5 M sucrose solution . All tests were compared with 2.5 M sucrose solution as the check. Test solutions were stored in a refrigerator, and were warmed to laboratory temperature before being used.A 1000 ppm stock solution of emamectin benzoate (MK-0244 5% SG) supplied by Merck Research Laboratories,  for 30 min on each toxicant concentration. Moths were fed with a range of concentrations of emamectin benzoate. Since feral males were not a limiting factor in the number of insects used per treatment, ten moths were fed on each concentration in each replication. Each concentration was replicated 5 times. A total of 300 moths were used in this test. Each moth was placed individually inside a onequart bottle, and was examined for mortality at 24, 48 and 72 h thereafter. A male was considered dead when it could not right itself when placed upside down.90), 6.5 ppm (5XLC90), 13 ppm (10XLC90), 32.5 ppm (25XLC90) and 65 ppm (50XLC90). Each adult was placed individually in a sealed plastic soufflè cup after feeding and observed for mortality at 15, 30 and 45 min and every hour thereafter until a 6 h period when checking was increased to 12, 18, and 24 h. The mid-point of the interval during which the adults were considered dead was used in calculations.To determine mean time to death, ten moths were fed emamectin benzoate at each concentration comprising of 1.3 ppm . The amount fed was determined from the differences between the before and after feeding weights of the tubes, after correcting for evaporation loss from tubes kept aside as control in each concentration.Each newly emerged laboratory-reared female was fed emamectin benzoate until satiation, which did not exceed 30 min, and was paired with an untreated male. The glass jars containing test moths were closed with a paper towel. A strip of paper towel was suspended from the mouth of each jar, which provided a substrate for the moths to climb and lay eggs. The moths were fed 10% sucrose solution in a 25 ml plastic soufflè cup with a lid through which a cotton wick was inserted. Dead males were replaced with live males during the test. Moths that remained in copula while mating were removed from the study.nd day, numbers of eggs in the used jars were counted and a sample of ca. 30 eggs was collected from the paper towel in each jar for three consecutive days from each concentration in each replication. Fecundity was assessed from 5 females in each concentration in each replication because of the difficulty in counting the eggs as they were deposited indiscriminately on paper towels, on the inside surface of the jars and on cotton wicks.Two tests with slightly different divisions of concentrations between 0 and 1 ppm were conducted to evaluate the reproductive effects of emamectin benzoate at sub-lethal concentrations. Females were fed emamectin benzoate at 0.0125, 0.025, 0.05, 0.075 and 0.1 ppm and 0.05, 0.1, 0.2, 0.6 and 1.0 ppm in Tests 1 and 2, respectively. Soon after gustation, the adults were transferred to clean jars, and paired with an untreated male. Beginning the 2H. zea moth transfers a spermatophore to the female at the time of mating  is shown as well. The goodness of fit, χ2 statistic, was used as the test criterion to describe the distribution of pupae by gender at the 5% level of probability.Analyses of variance of the data were conducted using PROC GLM procedures . When F-2 = 2.985 with 4 df for 24 h response; χ2 = 5.254 and 1.455 each with 3 df for 48 and 72 h responses, respectively). The χ2 values were less than the tabular values for appropriate degrees of freedom. The LC50 {(95% CL (confidence limits)} values for feral males were 0.7189 (0.5403–0.8742), 0.4644 (0.2016–0.7013), and 0.1892 (0.0687–0.295) ppm for 24, 48 and 72 h responses, respectively. The LC50 value for 24 h response was not significantly different from that for 48 h response. Also, the LC50 value for 48 h response was not significantly different from that for 72 h response. However, LC50 value for 24 h response was significantly different from that for 72 h response.Table 1 shows that for feral males captured in pheromone-baited traps, the dosage mortality equation approximated the 24, 48 and 72 h responses (χ90), 24 h at 6.5 ppm (5XLC90), 12.6 h at 13 ppm (10XLC90), 10.2 h at 32.5 ppm (25XLC90) and 9 h at 65 ppm (50XLC90). Relationship between LTs and concentrations of emamectin benzoate was inversely related and appears to level off asymptotically. The LTs at 13 ppm and higher were not significantly different and suggests an optimum concentration of 13 ppm for causing the quickest mortality.Mean lethal time for 48 h response varied significantly between concentrations of emamectin benzoate . H. zea.Emamectin benzoate significantly influenced proboscis extension response of feral males . Proboscis extension response was significantly depressed at 20 ppm and above compared with males fed 2.5 M sucrose solutions. Emamectin benzoate, however, did not significantly depress proboscis extension response of males at 4 ppm . These rH. zea females ingested significantly less emamectin benzoate at 1 ppm ( = 72.1 mg/♀), but this value was not significantly different from those which ingested 2.5 M sucrose solution.H. zea did not influence fecundity .Females deposited significantly fewer eggs at 0.0125, 0.025, 0.05 and 0.1 ppm compared with those fed 2.5 M sucrose solutions in day 1 of Test 1 . However, emamectin benzoate did not significantly influence fecundity either in day 2  or in day 3 of Test 1 . Also, when the total number of eggs deposited during 3 days of testing were pooled, ingestion of emamectin benzoate by female H. zea during all 3 days of testing in Test 2 . There was, however, no consistent trend favoring one treatment of emamectin benzoate over another in reducing fecundity of H. zea during three days of testing, probably owing to large variance. When eggs collected over a 3-dayperiod were pooled, the number of eggs deposited by H. zea varied significantly between treatments as well . The number of eggs deposited was the highest at 0.2 ppm with 1240 eggs/♀, but this value was not significantly different from females fed 2.5 M sucrose solutions. In spite of the large variance, a common trend from the data show that emamectin benzoate did reduce oviposition significantly at 0.6 ppm and above.In contrast with Test 1, emamectin benzoate significantly influenced fecundity of female In Test 1, emamectin benzoate significantly depressed percent larval hatch of eggs for all 3 days of testing. The ANOVA statistics for each of these 3 days were: day 1, F = 4.11, df = 5, 61, p <0.005; day 2, F = 13.29, df = 5, 65, p <0.001; and day 3, F = 20.69, df = 5, 61, p <0.001. Table 4 shows that in day 1, emamectin benzoate significantly reduced larval hatch at 0.05 ppm, and in day 2 and day 3, however, significant reduction in larval hatch occurred at a concentration as low as 0.0125 ppm. This suggests a cumulative effect of emamectin benzoate in reducing larval hatch on days 2 and 3 at a lower concentration compared with that on day 1. Emamectin benzoate significantly reduced larval hatch to less than 2% at 0.1 ppm on day 3. Overall trend for all 3 days of observations suggest that percent larval hatch of eggs deposited by females tended to decline significantly with ingestion of increasing concentrations of emamectin benzoate.H. zea.Similar to Test 1, emamectin benzoate significantly reduced percent larval hatch of eggs on all 3 days of testing in Test 2 (Table 5). The ANOVA statistics for each of these 3 days were: day 1, F = 8.73; df = 5, 47; p <0.001; day 2, F = 11.05, df = 5, 44, p <0.001; day 3, F = 9.60, df = 5, 40, p <0.001. In contrast to Test 1, reduction in percent larval hatch at 0.05 ppm and 2.5 M sucrose were comparable during all 3 days of testing. This discrepancy in reduction in percent larval hatch at 0.05 ppm between Test 1 and Test 2 probably reflects the difficulty in mixing the insecticide in a viscous medium such as the 2.5 M sucrose solution consistently using the serial dilution technique. Alternatively, it is likely that the use of 1 M sucrose in lieu of 2.5 M sucrose may produce more consistent mixing of test solutions. Reduction in percent larval hatch at 0.1 ppm and above on all three days of testing was more apparent and exhibited a more consistent dose response relationship. Similar to the trend observed in Test 1, reduction in larval hatch appears to be negatively related with ingestion of increasing concentrations of emamectin benzoate by female et al. . In contrast with Test 1, et al.  and Lath . 2 = 0.98; df = 5; p >0.96).Emamectin benzoate did account for a significant portion of the variability in larval survival to the pupal stage (Nparlway procedure: F = 93.42; df = 5, 6; p <0.0001; Kruskal-Wallis test: χet al. (H. virescens. Data presented here demonstrate that emamectin benzoate has good potential for use in an attracticide/stimulant formulation for areawide suppression of the H. zea. Emamectin benzoate kills adults upon ingestion at very low concentrations, although it is slow-acting. The extremely low amount of emamectin benzoate that suppresses larval hatch of eggs when ingested by laboratory-reared females is a promising characteristic and this coupled with the lack of inhibition of gustatory and proboscis extension at sublethal concentrations makes this chemical an ideal candidate for further research. Furthermore, White et al. (H. zea, relative to fecundity, fertility and mating frequency. Any spray applications against H. zea moths must occur during peak emergence of the insect and appropriate application techniques must be developed.The results reported in this study are in agreement with Argentine et al.  who repoe et al.  reportedH. zea is that it is not gender specific, and that feeding habits of both sexes could be exploited for control purpose. Targeting virgin H. zea populations before they mate and disperse for reproductive functions is potentially an effective strategy against nocturnal Lepidoptera. The attract-and-kill strategy for H. zea appears to be in a conceptual stage and field validation of results reported herein is warranted to move this technology forward.The major advantage of attract-and-kill strategy for


The success of this policy depends on early HIV diagnosis. One-third of individuals in the UK have a CD4 cell count <200 cells/mm3 at diagnosis.Current UK guidelines recommend initiation of HAART in all patients with a CD4 count of <350 cells/mm3 or presenting with an AIDS-defining event, regardless of the CD4 count.According to the European consensus, late presentation for care refers to persons presenting with CD4 cell count <350 cells/mmApplying only the current CD4 definition for late presentation, we examined the influence of age and calendar period on stage of HIV presentation and the impact of late presentation on mortality.Data were collected on patients diagnosed with HIV infection from 1st January 1996 to May 2010. Age was studied as a binary exposure variable (< 50 versus > 50 years). Patients were further stratified by time of diagnosis into 1996-2001, 2002-2005 and 2006-2010 periods. Logistic regression modelling was used to estimate the likelihood of late presentation. Poisson regression modelling was used to estimate mortality in the cohort.3 at HIV diagnosis. The median CD4 cell count for late presenters was 211 cells/mm3 (IQR 83-289). The majority of the cohort were white males and homosexual. After adjustments, individuals aged over 50 were more likely to present late . Late presentation was less likely in calendar periods 2006-2010 and 2002-2005 compared to 1996-2001 . Mortality rate in the cohort after 6719.80 person years (pyrs) of follow up was 15.33 per 1000 pyrs (95% CI: 12.64-18.59). After adjustments, age greater than 50  and CD4 cell count <350 at diagnosis  remained independently associated with increased mortality.1531 patients had documented CD4 cell counts within 3 months of diagnosis. The median age at HIV diagnosis for those under 50 and over 50 years was 33.3 (IQR 28.0-38.7) and 54.7 (IQR 51.9-60.6) respectively. 49% of the cohort had a CD4 cell count < 350 cells/mmIn our cohort, late presentation and mortality are decreasing; however, individuals older than 50 were more likely to present late and had a higher mortality. Initiatives to expand HIV testing in clinical and community setting should not neglect individuals aged over 50 whom are often erroneously perceived not to be at risk of HIV infection.


Simulium and tested the repellency of five essential oils extracted from Homalomena aromatica Schott , Pogostemon heyneanus Bentham , Citrus aurantifolia Swingle , Vitex negundo L. , and Ageratum conzoides L.  on the human volunteers against Simulium (blackflies) in three locations of Arunachal Pradesh, India. Blackflies preferred biting legs (> 79%) as compared to hand and face with profound biting activity during 1000–1100 h (> 23%) and 1500 – 1600 h (> 28%). The essential oil extracted from Homalomena aromatica, Vitex negundo and Ageratum conizoides provided > 2 h protection at 5% concentration and > 5 h protection at 10% concentration in all the three testing locations. The repellency of Homalomena aromatica, Vitex negundo and Ageratum conizoides essential oils after 6 h application was > 50% at 5% concentration and > 90% at 10% concentration. The study provides evidence for the potential of these essential oils in developing new repellents against blackflies.Use of repellents seems to be most reliable method of personal protection against annoyance and infections associated with haematophagous insects. We have investigated the biting activity of  Simulium species transmit Onchocerca volvulus which causes river blindness (onchocerciasis) in African countries  with temperature ranging from -2 to 10°C in winters and 10 to 30°C in summers. The inhabitants are agriculture farmers, woodcutters and hunters working from sunrise to sunset making themselves available for blackfly bites throughout the day.Homalomena aromatica and leaves of Pogostemon heyneanus, Citrus aurantifolia, Vitex negundo and Ageratum conizoides were extracted by steam distillation method using Clevenger type apparatus in the laboratory. The plants selected in the present study have a history of medical use. Blackflies pupae were collected using the methods of Puri et al. , S. barraudi Puri, S. kupari Datta, S. indicum Becher and S. rufibasis Brunetti were prevalent during the study period.Essential oils from the rhizome of i et al. , 1932b fHelianthus annus L. : , v/v at 10% concentration, from which 5%, 7.5% concentrations were prepared. Each trial was conducted using six volunteers  for each concentration of each essential oil in each of the three testing sites. Volunteers aged between 18 to 50 years participated in the study were non-smokers, non-alcoholic and had no known history of allergic reactions to insect bites or herbal oils. The written consents were obtained from each test volunteer prior to the commencing of trial. 1.5 ml dilution of each of three concentrations of each essential oil was applied at a rate of 1 ml per 500 cm2 topically on each arm from elbow to finger tips (area approx 750 cm2) and 2.5 ml on each leg from knee to foot (area approx 1250 cm2) of test volunteers after disinfecting the treatment area skin with alcohol  and other biting hours . The flies preferred biting legs (79.1%) rather than hand (17.7%) and face (3.2%) . The biting pressure at Dirang (3.12 ± 0.2) was significantly high  than in Salari (2.48 ± 0.3) and Tenga (1.84 ± 0.1).The biting activity of blackflies is presented in P ≤ 0.002, F ≥ 20.29) tested in all the three testing locations. There was no significant difference in the protection time produced by similar concentrations of an essential oil among the three testing locations . However the protection time produced by similar concentrations of all the tested essential oils in all the testing locations differs significantly (data pooled). In 5% concentration, A. conizoides essential oil protection time, 154.8 ± 8.4 minutes (APT ± SEM) was higher  but did not differ significantly from V. negundo (P > 0.05), whereas in 7.5 % concentration, protection time was higher in V. negundo (225.6 ± 4.8)  but was similar  to that in A. conizoides and H. aromatica. In 10% concentration, V. negundo essential oil protection time was 326.55 ± 4.8, which was significantly higher  but did not differ significantly from H. aromatica (P > 0.05). No bite was observed upto 2 h with 5% and upto 3 h with 7.5% topical application of H. aromatica, V. negundo and A. conizoides essential oils. However in P. heyneanus and C. aurantifolia the repellency fell to 88.42% and 85.26% respectively at 5% concentration after 2 h. After 6 h of application, H. aromatica, V. negundo and A. conizoides essential oils at 5% concentration produced > 50% repellency, whereas at 10% concentration > 90% repellency was achieved [The repellent activity of five essential oils tested against the biting of black flies in three different locations has been presented in achieved . The conAristolochia indica, Cassia angustifolia, Diospyros melanoxylon, Dolichos biflorus, Gymnema sylvestre, Justicia procumbens, Mimosa pudica and Zingiber zerumbet have been used as mosquito repellent and produced good results  and p-menthane-3, 8-diol—based repellent have produced 8–10 h protection time (Homalomena aromatica, Vitex negundo and Ageratum conizoides are very effective against blackflies in northeast India. Our findings are similar to those achieved elsewhere (In the present investigation essential oil of ion time . Howeverlsewhere . Preventlsewhere . Our finlsewhere  and Usiplsewhere , who sholsewhere  revealedlsewhere . These flsewhere . The repBiting activity of blackflies occurs in bimodal fashion being high in morning, as it was recorded high in morning hours and early evening hours. In the previous studies, Kutin et al. , Opara eVarious reports on the use of plant based materials for the management and control of various pest and vectors of disease agents have been documented. Herbal repellents provide a safe, eco friendly and inexpensive means to protect individuals from vector biting . The bioIn the present study we have found that the blackflies are more active during morning hours and early evening hours and prefer biting legs rather than hands or face. The potential plants based essential oils tested in the present study provided protection time > 5 h at 10% concentration, hence are suitable candidates as blackflies repellents. The essential oils appeared to have no toxic effects in this study and a history of herbal medicine use indicates safety, which is further confirmed here by the dermatological test carried on the mice model. The present results have clearly demonstrated the possibility of transforming the potential natural products into commercial repellent after testing in different geo-climates and blackflies species.


To the Editor: Seoul virus (SEOV), a member of the family Bunyaviridae, genus Hantavirus, is primarily carried by Rattus norvegicus rats. Because members of Rattus species are widely distributed, SEOV has the potential to cause human disease worldwide. It has been reported that SEOV causes a milder form of hemorrhagic fever with renal syndrome than Hantaan virus and Dobrava-Belgrade virus and is responsible for 25% of cases of hemorrhagic fever with renal syndrome in Asia  during the operation of a cooperative rodent surveillance program of China and North Korea. The captured rodents were euthanized with barbiturate (100 mg/kg), weighed, measured, classified by sex, and then autopsied. Lung samples were probed for the large segment of SEOV by reverse transcription PCR by using the RT primer P14  of 89 rodent samples tested positive for SEOV by reverse transcription PCR. Infection rates at each surveillance time were 26.7% (4/15) in September 2009, 7.5% (3/40) in June 2010, 28.6% (6/21) in September 2010, and 15.4% (2/13) in September 2011. All infected R. norvegicus rats were adults; 9 were male and 6 were female. The rate of nucleotide substitution in these 15 SEOV amplicons  was calculated by Bayesian Markov chain Monte Carlo analysis using BEAST 1.74 (7). The mean substitution rate, calculated by using the uncorrelated lognormal distribution relaxed molecular clock model and a Bayesian skyline model for the large segment of SEOV, was 8.27 × 10−3 substitutions/site/year, with a 95% high posterior density interval that ranged from 1.02 × 10−4 to 1.79 × 10−2. This substitution rate is about 3 times greater than that for middle and small segments  sequence analysis (data not shown), the fact that SEOV strain L0199 from Laos were not clustered in clade A-D(2) showed that Laos was another possible area of origin for SEOV.Our work contributes to the known epidemiology of exposure to the SEOV pathogen in Hyesan. Hyesan adjoins Changbai County in Jilin Province of China. However, SEOV was not detected in Changbai County during the surveillance program (data not shown), which was consistent with previous research (


This study was designed to assess the prevalence of metabolic syndrome and its correlated factors in an urban population in Ahvaz.This descriptive analytical study performed with random cluster sampling method in 6 health centers in Ahvaz. In each selected center, 55 households were randomly selected. A questionnaire included: age, sex, marital status, ethnicity, education level, family history of diabetes (DM), Hypertension (HTN) and obesity, smoking and parity and previous history of gestational diabetes Mellitus in women were filled for each person.Blood pressure, weight, height, body mass index (BMI), abdominal and waist circumference were measured in each participant. Fasting blood glucose (FBS), serum total cholesterol, triglyceride and high density lipoprotein (HDL) level were measured in fasting blood sample.The mean age of all participants was 42.27 ± 14 years (44.2 ± 14.26 years in men and 40.5 ± 13.5 in women). From total 912 participant, 434(47.2%) were men and 478(52.8%) women. Prevalence of metabolic syndrome based on ATPIII criteria (update2005) was 22.8% (15.9% in men and 29.1% in women) that showed significant difference (P = 0.0001). Prevalence of each component of MS in studied population was: 29.4% for abdominal obesity, 40.7% for high TG level, 40.2% for low HDL, 15.4% for hypertension and 37.8% for abnormal FBS. Among these factor, age of patients, BMI, sex had significant differences between persons with or without Ms (P = 0.0001). Ethnicity (Arab or Persian), cigarette smoking and family history of diabetes mellitus, hypertension and obesity, marital statues, education level, parity and previous history of GDM in women showed no significant differences between persons with MS and without MS.Metabolic syndrome has high prevalence in our population and its prevalence increases with increasing age and BMI. Women are at higher risk for metabolic syndrome than men.The online version of this article (doi:10.1186/2251-6581-12-11) contains supplementary material, which is available to authorized users. Metabolic syndrome (MS) or X syndrome refers to simultaneous occurrence of cardiovascular risk factors or type 2 diabetes such as abdominal obesity, high blood pressure and abnormal carbohydrate and lipid metabolism  and decrease in high density lipoprotein (HDL) level . AlthougStudies in different provinces in Iran showed that the prevalence of metabolic syndrome was between 21.9% to 31.1% , 14. ManThis descriptive analytical study performed with random cluster sampling method in 6 health center in Ahvaz. In each selected center, 55 households were randomly selected. After obtaining informed consent by volunteers, they were invited to participate in this study.2], abdominal and waist circumference were measured in each participant. Blood pressure was measured by a standard sphygmomanometer after 15 minutes rest in a sitting position. The cuff was placed on the right arm at the heart level and then quickly pushes the device until 30 mm Hg above radial pulse disappearance. Blood pressure was measured twice at least 30 minutes interval between two measurement and mean of these two measurements, was taken as blood pressure. Anthropometric measurements were taken after removing shoes and wearing a light dress. Weight and height were measured according to the standard program. Waist circumference was measured at the midpoint between the lowest rib and the upper lateral border of the right iliac crest and hip circumference at the point of maximum hip diameter.A questionnaire included: age, sex, marital status, ethnicity, education level, family history of diabetes (DM), Hypertension (HTN) and obesity, smoking and parity and previous history of gestational diabetes Mellitus in women were filled for each person. Blood pressure, weight, height, body mass index (BMI) [Weigh(kg)/Height(m)After 12 h of fasting, blood samples were taken in the morning. Samples was centrifuged, serum stored in the refrigerator and was sent to Diabetes Research Center laboratory.Triglyceride (TG), Fasting Blood Sugar (FBS), Cholesterol and high density lipoprotein (HDL) were measured using an enzymatic colorimetric method with Pars Azmoon kit. .Abdominal obesity (Waist circumference ≥ 102 cm in men and ≥ 88 cm in women).TG ≥ 150 mg/dl or history of drug consumption for hypertriglyceridemia.HDL ≤ 40 mg/dl in men and ≤50 mg/dl in women or history of drug consumption.BP Siastolic ≥ 130 mmhg or BP diastolic ≥ 85 mmhg or history of anti hypertensive drug consumption.FBS ≥100 mg/dl, history of diabetes mellitus history or using anti diabetic drugs.For diagnosis of metabolic syndrome at least three of the following five components were considered necessary (according to ATP III criteria update 2005) , 20.AbdoSample size was calculated as 912 and EPI2000 descriptive statistics was used to provide figures and tables. Chi-square test, logistic regression and trend test was used for correlation assessment SPSS software 19 and EPI2000 descriptive statistics was used to provide figures and tables. P = 0 < 0.05 was considered as significant.From total 912 participant, 434 (47.2%) were men and 478(52.8%) women. The mean age of all participants was 42.27 ± 14 years (44.2 ± 14.26 years in men and 40.5 ± 13.5 in women). Prevalence of metabolic syndrome based on ATPIII criteria (update2005) was 22.8% (15.9% in men and 29.1% in women) that showed significant difference (P = 0.0001).Trend test showed increased prevalence of metabolic syndrome with increasing age in total sample and both sexes. P = 0.0001) . Prevalence of each component of MS in studied population was: 29.4% for abdominal obesity, 40.7% for high TG level, 40.2% for low HDL, 15.4% for hypertension and 37.8% for abnormal FBS (15.3% DM and 22.6% impaired fasting glucose (IFG).Abdominal obesity showed highest prevalence in age group 50–59 years (39.1%). High TG was more prevalent in 50–59 years group 52.2%) and Low HDL in 30–39 years (47.3%). The highest prevalence of high blood pressure and abnormal FBS were seen in age group ≥ 70 years (50% and 62.1% respectively) Prevalence of each component of MS in both sexes in each age group was shown in Table .2% and LIn total subjects, 22% were normal (no any component of MS) 29.9% had one component, 26.1% two, 13.8% three, 6.9% four and 1.4% have five component of metabolic syndrome . The prevalence of hypertriglyceridemia was higher in men (47.8%) than women (34.2%) with significant difference (P = 0.0001). Low HDL was detected in 50.7% of women and 28.5% of men with significant difference (P = 0.0001). Rate of high blood pressure (BP ≥ 130/85) in men was 13.7% and in women 16.9% with no significant difference (P = 0.17). Prevalence of high FBS was 40.8% in men and 35.1% in women that showed significant difference (P = 0.041). Factors that can affect the incidence of MS are seen in Table Among these factor, age of patients, BMI, sex, had significant differences between persons with or without MS (P = 0.0001). Ethnicity (Arab or Persian), cigarette smoking and family history of diabetes, hypertension and obesity, marital status, level of education, and parity number and previous history of GDM showed no significant differences between persons with MS and without MS (P > 0.05).The metabolic syndrome is an important risk factors for diabetes type 2 and cardiovascular diseases, thus the clinical implication of diagnosis of MS is identification of patients who needs aggressive life style modification –23.The results of this study showed that the prevalence of metabolic syndrome is high in studied population and it increases with increment of age and BMI significantly. The prevalence of MS was 22.8% (15.9% in men 29.4% in women) with significant difference. Smoking, ethnicity, level of education, family history of diabetes, hypertension and obesity, marital status, and parity and history of GDM in women had no effects on prevalence of MS.The prevalence of MS in this study is similar to studies in Zanjan 23%  and ZahePrevalence of low HDL in our study was 40.2%, but in Tehran study it was 63% , in YazdGenetic factors are important in the incidence of low HDL. Existence of specific genes in addition to nutrition and physical activity and smoking can have effect on the prevalence of low HDL –30. The In DECODE study that was conducted in 9 European countries, MS was detected in 32% of men and 28.5% of women , Turkey In a recent study in Korea  MS was sMany factors including: age, race, weight, menopause in women, smoking, low income economies, high carbohydrate intake, no alcohol consumption, low physical activity , consumpA parental history of metabolic syndrome increases the risk, and genetic factors may account for as much as 50% of the variable in level of metabolic syndrome traits in offspring –36. In mStrengths of this study are that it is a population based study in an urban population of Iran, extensive information of confounders and a relatively large sample size. One limitation was that, this study was cross sectional that does not allow us to draw any causal interference. Therefore in the future large prospective studies should be used to confirm the association between above mentioned factors and metabolic syndrome.Metabolic syndrome has high prevalence in our population and its prevalence increases with increasing age and BMI. Women are at higher risk for MS than men.


Haemophilus influenzae carriage are still remaining unclear. Especially it concerns such a group as children with low immune status and also such groupas children with tuberculosis infection. We examined nasopharyngeal tract of children with tuberculosisinfection in remission and checked how often these children are carriers of Haemophilus influenzae strains. Also we gained microbiology characteristics of the isolates and defined the clinical significance ofH. influenzae carriage in development of opportunistic infections in children with the tuberculosis infection.Being rigorously studied, epidemiology aspects of  Despite improvements in diagnosis, treatment,and preventive measures, tuberculosis remains an important cause of morbidity globally. In the Primorye Region of far east Russia (population 2000.000), the incidence of tuberculosis in 2008 was 105.7 per 100.000 and with a prevalence of 222 per 100.000. For children under 17 years, the incidence of tuberculosis was 36.6 per 100.000. In 2008, there were 108 cases of tuberculosis in  children under 11 years, and 83 cases in children from 11 to 17 years . Mortality increased by 20.7% compared to 2000. In the pediatric population, pulmonary tuberculosis accounted for 90.9% of all tuberculosis in 2008, up from 72.7% in 1999.It was recognized that children treated for tuberculosis were more often ill with other bacterial respiratory tract infections than children without such comorbidity. There are several possible contributing factors to this, for example, impaired immune status, malnutrition, and low  socioeconomical status of their family. However, other important factors could be the regular antimicrobial (antituberculosis) chemotherapy they receive or attendance at the Pediatric Tuberculosis Center for anything between 20 and 180 days, according to the current tuberculosis treatment protocol. As the main focus for such patients is the treatment of tuberculosis, the problem of other bacterial respiratory tract infections could be underestimated. H.influenzae in children with tuberculosis or children from closed communities [There are some data on the carriage of bacterial respiratory tract pathogens in children with various comorbidities –5, but lmunities .H. influenzae in the  nasopharynx of children with tuberculosis and to assess antimicrobial susceptibility of these bacteria. We aim to study the prevalance of We examined 85 children from the Pediatric Tuberculosis Center (Group 1), all of whom had taken antituberculosis chemotherapy within the previous 1.5-2  months, with rifampicin, isoniazid, ethambutol, and streptomycin (according to WHO recommendations). They had received their treatment in the Pediatris Tuberculosis Center sanatorium for up to 3 months. Of the 85 patients in Group 1, 36 patients (42.3%) had tuberculosis intoxication, 28 patients (32.9%) had post-BCG complications, and 21 patients (24.7%) had extrapulmonary tuberculosis. Group 1 consisted of 41 patients (48.2%) under 5 years of age, 28 patients (32.94%) aged 6–10 years, and 16 patients (18.8%) aged 11–15 years. All Group 1 patients took low doses of rifampicin as recommended by the Public Health Ministry. A control group (Group 2) consisted of age-matched children without tuberculosis attending the pediatric sanatorium with gastrointestinal pathology (70 patients).Nasal- and oropharyngeal swabs were taken from both groups of children using nylon flocked  swabs and a liquid transport medium, which were plated onto an appropriate medium . H. influenzae strains was confirmed by the use of X factor (hemin), V factor (nicotinamide-adenine dinucleotide), and X+V factor disks  on  nutrient agar plates according to the manufacturer's instructions. Serotypes were determined by means of a coagglutination technique with antiserum against serotype bcapsular polysaccharide and polyvalent antiserum for serotypes a, c, d, e, and f . The following six strains were used as positive controls for  serotypes a, b, c, d, e and f, respectively : ATCC 9006, ATCC 10211, ATCC 9007, ATCC 9332, ATTC 8142 and ATCC 9833. Initial typing results were confirmed by typing all strains by PCR by the method of Maaroufi [β-lactamase was detected with  nitrocefin disks . Antimicrobial susceptibility was determined by disk diffusion and microdilution methods according to CLSI  standards and breakpoints. For macrolides (clarithromycin), resistance was taken as  MIC ≥ 32 mg/L, for rifampicin, it was about ≥ 4 mg/L, and for ampicillin it was ≥ 4 mg/L. The study was approved by the Local Human Investigations Committee. Data were analysed according to common statistical methods, including incidence and prevalence analysis and odds ratio (OR) calculating for risk factors analysis.The identification of More than 60% of the children with tuberculosis had acute pathology of upper and lower respiratory tract of nontuberculosis etiology more than 8 times per year. Children younger of 5 years with tuberculosis had upper respiratory tract pathology more often (OR = 9.0) than children of the same age without tuberculosis. In children without  tuberculosis, there were only 8 who had acute pathology of upper and lower respiratory tract more than 5 times per year).H.influenzae were isolated from 43 patients in Group 1, and 23 strains from 18 patients in the control group (Group 2). The results are presented in A total of 51 strains of H. influenzae more often  than children from Group 2 (25.5% 18 patients). It is notable, however, that antimicrobial consumption was much higher in children of the 1st Group (P =  0.003). Children in Group 1 often harbored more than 1 strain of H. influenzae. Children from Group 1 carried P <  0.05).From Group 1 children, there were 51 strains isolated from 43 patients. Only one strain in 26 patients (60.4%), and 2 and more strains in 17 patients (39.5%). From Group 2 children, there was a single strain from13 patients (18.57%) and 2 or more strains from 5 patients   were typable, and only 8.57% (6 strains) were nontypable strains of H. influenzae. In Group 1 the types were type B 47.82 % (11  isolates), type A  13.04 % (3 strains), type F 17.31% (4 strains), type D 8.69% (2 strains), and type C 13.04% (3strains). In Group 2, the types were 15,7% (11isolates) of type B, 2.85% (2 isolates) of type D, 2.85% (2 isolates) of type C, and 2.85% (on 1  isolate) of types E and F.The prevalence of different serotypes of Haemophilus genus was also different in children from Group 1, compared to children in Group 2. In Group 1, 54% (28 strains) were nontypable, and 46% (23 strains) were typable  Regarding beta-lactamase production, there were 12 beta-lactamase-positive strains (23.5% ) in Group 1 and just 2 beta-lactamase-positive strains (2.85%) in Group 2. One explanation for this finding is the higher consumption of antimicrobial agents in Group 1 children.The strains from Group 1 children  were resistant to rifampicin 15.6% , ampicillin 31.37% , clarithromycin 21.5% , cotrimoxazole 9.08% . The strains from Group 1 children  were resistan to ampicillin 1.42% , and there was no resistance to rifampicin.H. influenzae suffered from rhinosinusitis for an average of 136 days per year and from otitis media for 92 days per year. Children with tuberculosis but without carriage of H. influenzae suffered from otitis media for 14 days per year.Further investigations revealed that patients who carried The carriage of potential bacterial respiratory pathogens in children treated for tuberculosis is underestimated.   The application of molecular epidemiology methods may determine if these organisms are hospital or  community acquired.


Escherichia coli and Klebsiella pneumoniae bacteria isolated from clinical samples of patients attending Imam Reza and Ghaem University Hospitals, Mashhad, Northeast of Iran.Production of extended-spectrum beta-lactamases (ESBLs) by enteric bacteria continues to be a major problem in hospitals and community. ESBLs producing bacteria cause many serious infections including urinary tract infections, peritonitis, cholangitis and intra-abdominal abscess. The aim of this study was to determine the prevalence of ESBLs producing E. coli and 78 strains of K. pneumoniae were isolated from out-patients and hospitalized patients and they were examined by Oxoid combination disk test and PCR methods.During 2009 and 2010, 82 strains of E. coli and 56.1% of K. pneumoniae produced ESBLs. The frequency of SHV and TEM among the ESBLs producing isolates were 14.4% and 20.6%, respectively. Ratios of ESBLs positive isolates from out-patients to hospitalized patients were 24/33.We found that 43.9% of E. coli and K. pneumoniae is high in both study groups . Therefore it seems that continuous surveillance is essential to monitor the ESBLs producing microorganisms in hospitals and community. This study shows that the prevalence of ESBLs producing  Beta-lactam antibiotics are the most common drugs of any application in the treatment of bacterial infections . The betKlebsiella pneumoniae is the most common bacterial production of ESBLs; similarly, Escherichia coli is the other very important microorganism. ESBLs productions are rarely observed among other bacteria 8 cfu/ml (0.5 McFarland standard) were prepared in nutrient broth. Oxoid combination disk method was used for detection of ESBLs producing organisms. In this method the bacteria were cultured on a Muller-Hinton agar plate, then cefotaxim (30 µg), cefotaxim/clavulanate (10 µg), ceftazidime (30 µg) and ceftazidime/clavulanate (10 µg) disks  were placed on media in 20-30 mm with other disks. The plates were incubated for 18-24 hrs at 37 °C. ESBLs producing organisms were detected by an at least 5 mm increasing of zone around cefotaxim/clavulanate and ceftazidime/clavulanate at least 5 mm.For ESBL assay, bacterial suspensions with concentration of 1.5×10DNA extraction, PCR and sequencingThe colonies of ESBLs producing organisms were suspended in TE buffer and their DNA were extracted by simple boiling . 2, 0.2 mM each dNTP, and 5 u Taq DNA polymerase  in a total number of 50 μl of PCR reaction. Amplification of TEM and SHV genes was performed by following program: initial denaturation at 94 °C for 2 min and 35 cycles of 1 min at 94 °C, 30 sec at 52 °C and 1 min at 72 °C. Five min at 72 °C was considered for the final extension. Then, PCR products were analyzed by agarose gels electrophoresis. Eight PCR products from different types of the samples were sent for sequencing to Microgene Company, .The PCR method for detection of SHV and TEM genes was performed as described previously with minor modifications (14-15); briefly, specific primers for the genes  were used for PCR amplification that produced 471 bp and 861 bp PCR products for SHV and TEM genes, respectively. The PCR mixture consisted of 10 pmol of each primers, 1 μl DNA sample (3 μg/μl), 1.5 mM MgClE. coli n=82, K. pneumoniae n= 78) were collected; of these 57 isolates (35.6%) were ESBLs producing organisms (E. coli and 32 (20%) of isolated K. pneumoniae were ESBLs producing organisms.Among all the samples, urine samples were the most positive ones . In this study, a total number of 160 bacteria isolates .The distribution of ESBLs producing organisms based on out-patients and hospitalized patients are shown in In PCR method the distribution of TEM and SHV genes in isolated ESBLs producing organisms were 33 (20.6%) and 24 (14.4%), respectively , Table 3 sequenced and reported as Iranian strains in Gen Bank . The results obtained from sequencing was compared with the published sequences in Gen Bank and it showed that there was 99-100% (for SHV beta-lactamase gene) and 100% (for TEM-1b beta-lactamase gene) homology between our PCR products and those mentioned in Gen Bank.Eight PCR products from different kinds of samples wereE. coli and K. pneumoniae and to detect the presence of TEM and SHV genes among ESBL producing isolates. Based on the results of this study, the prevalence of ESBL producing E. coli and K. pneumoniae was high  and a total number of about 68.5% of ESBL producing isolated bacteria were TEM and/or SHV positive. A number of previous studies have showed the high prevalence of ESBLs producing E. coli and K. pneumoniae. In , the prevalence of ESBLs producing E. coli and K. pneumoniae isolates varies in different countries. In , the prevalence of the organisms was reported 46.51% in E. coli and 44.44% in K. pneumoniae isolates . In our study, the prevalence of ESBLs producing E. coli and K. pneumoniae was 15.6% and 20%, respectively.Reported ESBLs producing rates in et al in 2007 in Mashhad, the prevalence of ESBLs producing E. coli and K. pneumoniae was reported 57.5% and 61% and generally the prevalence of ESBLs producing organisms were 59.2% by Kirby-Baure disk diffusion method and the phenotypic disk confirmatory test. They also showed that the ratios of ESBLs producing isolates from hospitalized patients to out-patients were 94 to 28   . In Isfabacteria . Their ret al and Ramazanzadeh's results , and SHV (14.4%) genes by PCR. The TEM gene has high frequency compared to SHV gene; a fact which is similar to previous studies , 29 but  results , 31. AlsE. coli had 85.6% TEM, 69.2% SHV and 53.8% in both genes that was much higher than in our results (E. coli and K. pneumoniae) were also positive for SHV (52.7%) and TEM (32.4%) genes  genes ; and theIn short, the prevalence of ESBLs producing organisms in Mashhad is high. It seems necessary for clinicians and health care systems to be fully aware of ESBLs producing microorganisms. Also, the ESBLs production monitoring is recommended to avoid treatment failure and suitable infection control in Iran.


Electrochemotherapy is a local anticancer treatment very efficient for treatment of small cutaneous metastases. The method is now being investigated for large cutaneous recurrences of breast cancer that are often confluent masses of malignant tumour with various degrees of inflammation. To this end 18-Flourine-Flourodeoxyglucose-Positron Emission Tomography/Computed Tomography (FDG-PET/CT) could be a method for response evaluation. However, a standard FDG-PET/CT scan cannot differentiate inflammatory tissue from malignant tissue. Dual point time imaging (DTPI) FDG-PET has the potential of doing so. The purpose of this study was to investigate if DTPI FDG-PET/CT could assess response to electrochemotherapy and to assess the optimal timing of imaging.Within a phase II clinical trial 11 patients with cutaneous recurrences had FDG-PET/CT scans at three time points: 60 min, 120 min and 180 min after FDG injection. The scans were performed before and 3 weeks after electrochemotherapy.A significant reduction in maximum standard uptake value at 60 min post injection was seen after treatment. Furthermore a change in the FDG uptake pattern was observed; from increasing uptake in up to 180 min post injection before treatment to stabilization of FDG uptake at 120 min post injection after treatment. The change in FDG uptake pattern over time lead to change of response in three target lesions; two lesions changed from stable metabolic disease to partial metabolic response and one lesion changed from partial metabolic response to stable metabolic disease. To ensure detection of the change in uptake pattern, scanning 60 and 180 min post injection seems optimal.The present study shows that FDG-PET/CT 60 and 180 min after tracer injection is a promising tool for response evaluation of cutaneous recurrences of breast cancer treated with electrochemotherapy. Could dual time point imaging (DTPI) fluorine-18 fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) be a useful tool for imaging of recurrent breast cancer treated with electrochemotherapy? The 5-year incidence of loco-regional recurrence of breast cancer is reported to be between 6% and 23% following mastectomy and approximately 6% after breast conserving surgery and radiotherapy.Electrochemotherapy is a local treatment using electric pulses to transiently permeabilize the cell membrane.FDG-PET/CT scan is a highly accurate method for staging of breast cancer recurrence.In this study we investigated DTPI FDG-PET/CT as a possible method for response evaluation of loco-regional recurrent breast cancer treated with electrochemotherapy. This was done in order to evaluate if the method can assess treatment response to therapy and to determine the optimal timing of imaging FDG uptake in the loco-regional recurrence of breast cancer in this setting.In the period October 2008 to October 2010 patients with cutaneous loco-regional recurrence of breast cancer were prospectively accrued for a phase II investigator initiated electrochemotherapy protocol.clinicaltrials.gov identifier: NCT00744653), and the Data Protection Agency.Electrochemotherapy was considered when no other treatment options were available and patients had symptoms from large (> 3 cm) cutaneous loco-regional recurrence of breast cancer. All patients gave informed written consent and the protocol was approved by the Regional Research Ethics Committee, The Danish Medicines Agency  and contrast enhanced CT scan of the thorax was performed in each patient at baseline and at follow up. Furthermore, PET scanning was performed 120 min p.i. and 180 min p.i at baseline and at follow up. Patients fasted for at least 6 hours before the examination. A blood sample determined glucose level  before FDG administration to ensure the inclusion criteria of euglycemia (concentrations below 120 mg/dL). All examinations were performed with a Gemini PET/CT system , consisting of a dedicated germanium oxyorthosilicate full-ring PET scanner and a dual-slice helical CT scanner. After intravenous injection of 18F-FDG (370 MBq), the patients rested in a quiet room for 45 min. The scans were performed with the patients in supine position with arms over the head and were initiated with a low-dose CT scan  covering the thorax and used for attenuation correction. Thereafter, emission measurements were performed in the 3-dimensional mode with a 144 × 144 matrix (60 min p.i.). Emission scan time per bed position was 2 min; 4 bed positions (field of view: 155 mm) were acquired. After the first emission scan, a diagnostic CT scan of the thorax was performed after automated intravenous injection (100 mL 5 mL/sec) of iodine-containing contrast medium . Scan delay after injection was 50 seconds. Diagnostic dual-slice CT with an axial field of view of 600 mm and a matrix of 512 × 512 was performed in the spiral mode under continuous acquisition at 120 kV and 145 mA . The patients were then resting in comfortable chairs in the waiting room for two further emission scans of the thorax at 120 and 180 min p.i. The average examination time (including rest periods) was approximately 4 hours. Total time spent in the scanner was approximately 30 min.Assessment of tumour response in target lesions was done in accordance with RECIST 1.0: CT scans were analysed by an experienced radiologist using Eclipse Cone Planning version 8.9 , standardly used for radiotherapy planning. The largest diameter of target lesions in the axial plane was recorded and the sum of the diameters evaluated in accordance to RECIST.26PET data were reconstructed iteratively with a method based on the row action maximum-likelihood algorithm (RAMLA) using the PETView software . Image analysis and measurements were performed by a specialist in nuclear medicine in collaboration with the oncologist responsible for the treatment. Tumour tracking in the Brilliance Workspace soft ware package  was used. This allowed simultaneous viewing and analysis of the PET scans acquired at 60, 120 and 180 min p.i. Scans at baseline and follow up were analysed separately. The FDG uptake in target lesions were assessed semiquantitatively by measuring the maximum standardized uptake value (SUVmax) within a three dimensional ellipsoidal volume of interest (VOI) covering the target. SUV’s normalized to body weight were automatically drawn by isocon-touring in the selected VOI. SUV of 2.5 was used as cut off for the isocountoring. Background activity was determined as the SUVmax in the aortic arch using a spherical VOI with a diameter of 1.2 cm. Lesions outside the treated area and new lesions were not considered in this study. SUVmax in each target lesion was recorded at baseline and at follow up at 60, 120 and 180 min p.i. A complete metabolic response (CMR) was considered as visual disappearance of tumour activity in the target lesion, so that it became indistinguishable from surrounding normal tissue. Partial metabolic response (PMR) was considered when more than a 25% decline in SUVmax was observed, progressive metabolic disease (PMD) was considered when more than a 25% increase in SUVmax was observed and stable metabolic disease (SMD) was defined as not CMR, PMR or PMD as suggested limits in the EORTC criteria.27All of the quantitative values were expressed in terms of mean ± SD. A paired t-test was applied to determine the difference in SUVmax at baseline and at follow up. Repeated measurement analysis using general linear model was applied to determine the difference in SUVmax at 60, 120, and 180 min p.i. A p value of <0.05 was considered significant. Statistical analyses were performed using SPSS for windows version 16.0.The eleven evaluable patients with cutaneous loco-regional recurrence of breast cancer presented with a total of 16 target lesions . Baseline DTPI FDG-PET/CT was performed five days  before electro-chemotherapy and follow up DTPI FDG-PET/CT was performed 23 days  after electrochemotherapy.Before treatment the mean tumour diameter was 8.5 ± 6.3 and after treatment the mean tumour diameter was 7.0 ± 5.8 cm with a mean difference of 1.5 ± 2.5 cm (p=0.024). Observed responses were CR in two lesions, PR in three lesions, SD in 10 lesions, and PD in one lesion, resulting in objective response in 5 out of 16 lesions (31%) .Axial diameter and volume of the treated lesions were measured at baseline  before electrochemotherapy) and at follow up  after electrochemotherapy). Mean tumour diameter at baseline was 8.2 ± 6.0 cm and at follow up 6.4 ± 5.5 cm with a mean difference of 1.8 ± 2.9 cm (p=0.026).Observed responses were CR in 2 lesions, PR in 7 lesions, SD in 5 lesions, and PD in 1 lesion, resulting in objective response of 9 out of 16 lesions (56%) .At baseline  before electrochemotherapy) mean SUVmax in target lesions was 8.7 ± 6.1 at 60 min p.i., 11.0 ± 8.2 at 120 min p.i., and 13.4 ± 9.2 at 180 min p.i. The corresponding mean SUVmax for background was 1.7 ± 0.3 at 60 min p.i., 1.4 ± 0.2 at 120 min p.i., and 1.3 ± 0.4 at 180 min p.i. . Mean peAt follow up  after electrochemotherapy) mean SUVmax in target lesion was 5.7 ± 5.0, 7.2 ± 6.9, and 7.3 ± 6.8 at 60, 120, and 180 min p.i. respectively. The corresponding mean SUVmax for background was 1.8 ± 0.4, 1.5 ± 0.4, and 1.4 ± 0.5 . Mean peThe mean changes in SUVmax between baseline and follow-up scans were 3.1 ± 3.1, 3.8 ± 3.8, and 5.9 ± 6.0 at 60, 120, and 180 min p.i. respectively. Mean percentage changes of SUVmax between baseline and follow up scans were 38 ± 38% (p=0.001), 37 ± 47% (p=0.001), and 47 ± 46% (p=0.002) at 60, 120 and 180 scans respectively.At the 60 min p.i. scans CMR was observed in 2 lesions, PMR in 7 lesions, SMD in 6 lesions, and PMD in 1 lesion. The corresponding responses observed at the 120 min p.i. scans were CMR in 2 lesions, PMR in 7 lesions, SMD in 6 lesions, and PMD in 1 lesion. Observed responses at the 180 min p.i. was CMR in 2 lesions, PMR in 9 lesions, SMD in 3 lesions, and PMD in 1 lesion . One patet al.et al.In this study of 11 patients with cutaneous loco-regional recurrent breast cancer, 16 lesions where treated with electrochemotherapy and evaluated with DTPI FDG-PET/CT. We observed two changes between the baseline and follow-up PET-scan: a significant reduction in SUVmax 60 min p.i. after electrochemotherapy (standard imaging protocol) and a change in the SUVmax pattern from a steadily increasing SUVmax in up to 180 min before electrochemotherapy to a stabilization at 120 min p.i. on the after electrochemotherapy, making the difference in SUVmax before and after electrochemotherapy more pronounced using the 180 min p.i. scan. A significant reduction of SUVmax 60 min p.i is in routine anti-cancer treatment monitoring used as a surrogate parameter for tumour response and we interpret it as response to the electrochemotherapy in our study. This interpretation is strongly supported by the change in uptake pattern: after treatment the SUVmax stabilizes after 120 min in contrast to the baseline scans, where there is a steadily increased uptake in up to 180 min. This might indicate more tissue with inflammatory cells than with malignant cells at follow up as the SUVmax reaches a plateau in inflammatory cells faster than in malignant cells.Clinical examination with measurement of lesion extension is used for evaluation of electrochemotherapy and was also done in this study. CR was observed in two target lesions, PR in three, SD in 10 lesions and PD in one lesion using this method. It is difficult to measure the extent of the lesions in a clinical setting. The FDG-PET/CT scans showed a different picture from the clinical evaluation with more patients having partial response than patients having stable disease.Other forms of PET scanners such as the Positron Emission Mammography has shown high accuracy and appears useful in biopsy guidance, surgical planning and surveillance for recurrence With DTPI PET the time course of FDG uptake can be used to differentiate inflammation from malignancy which further improves the evaluation of response. The change in FDG uptake over time did change the response in three target lesions; in two lesions from SMD to PMR and in one lesion from PMR to SMR compared to the 60 min scan. To confirm our observations further studies could include biopsies, to determine the extent of inflammation and malignant tissue after treatment. Induction of inflammatory papules in the skin could also be of interest in evaluating the control time course of FDG uptake in inflammatory tissue. This was not done in this primary study.Although DTPI FDG-PET/CT is an experimental, expensive and time consuming investigation not favourable for routine clinical application, we do find it a promising non-invasive method for response evaluation of cutaneous loco-regional recurrent breast cancer treated with electrochemotherapy. Furthermore it can be of use in deep seated tumours In conclusion, this study indicates that not only FDG-PET/CT but also DTPI FDG-PET/CT is promising for evaluation and planning of electrochemotherapy and could be useful for other localized anti-cancer treatments as well. Although further studies are needed, a planned scan time at 180 min would be feasible and could add important information in particular when inflammation and cancer are superposed.


The aim of the study is to describe the hemodynamic changes and relate them to the changes in B-type natriuretic peptide (BNP) following fluid challenge in patients with severe sepsis and septic shock.This prospective observational study enrolled 30 patients with severe sepsis or septic shock who required a fluid challenge within 48 hours of admission to the ICU. All patients had a basic cardiac echocardiogram (echo) performed, blood for BNP collected and baseline hemodynamic measurements recorded. A 500 ml colloid challenge was administered within 30 minutes. The echo and hemodynamic measurements were repeated at this point. One hour after the fluid challenge the BNP test was repeated.P = 0.01) to 5.38 cm and 3.39 cm but within the reference thresholds. The BNP increased by 53.6% in the EF <50 group in contrast to a decrease by 12.7% in the EF >50 group. The median EF in the EF <50 and EF >50 groups were significantly different (0.44 vs. 0.66 respectively). Multiple regression analysis found LV dimension at end diastole at baseline was one of four independent predictors of an increase in %BNP.One patient was excluded due to missing data. There were significant increases in mean arterial pressure (MAP), left ventricular dimensions at the end of diastole and systole, stroke volume (SV), cardiac output (CO) and BNP after the fluid challenge, while the heart rate decreased. Impaired cardiac contractility was defined as an ejection fraction (EF) <50%. The left ventricular end-systolic dimension (LVESd) before (4 cm vs. 2.9 cm) and after the fluid challenge (4.2 cm vs. 3.29 cm) was significantly greater  in the EF <50% group compared to the EF >50% group. In the group with EF <50, the median LVEDd2 and LVESd2 post fluid challenge increased to values of 5.72 cm and 4.28 cm respectively (above the reference thresholds). For the group with EF >50, the median post-challenge LVEDd2 and LVESd2 increased significantly  may indicate that cardiac contractility is impaired and the LV dilated, indicating a strategy away from fluid resuscitation and towards inotrope use.


Aim. To evaluate the impact of SPARC on female sexual function. Methods. 151 women with a mean age of 60 ± 11.90 and SUI had a complete urodynamic investigation and underwent SPARC operation. 98 women completed the validated female sexual function index questionnaire (FSFI) at baseline and 94 women at follow-up. A minimum follow-up of 12 months was required for study inclusion. Results. 52/98 women were sexually active at baseline. Postoperatively only 33 patients were sexually active. The FSFI score of all 33 pre- and postoperative sexually active women increased from 25.3 ± 5.7 at baseline to 27.4 ± 4.8 at follow-up (P = 0.1). Scores of women with reduced sexual function at baseline increased significantly in the domains desire, arousal, and lubrication as well as orgasm and satisfaction and total FSFI-score (P = 0.002) postoperatively. Conclusions. Our results suggest that the SPARC-sling procedure for SUI did not negatively interfere with female sexual function. Female urinary incontinence is defined by the International Continence Society as the complaint of any involuntary leakage of urine . It is aSurgical treatment of SUI in women offers relatively high success rates and immediate improvement of SUI symptoms. The Female Stress Urinary Incontinence Clinical Guideline Panel of the American Urological Association found that pubovaginal slings, midurethral tapes, and retropubic suspensions were the most effective surgical techniques for SUI in women . Several long-term outcome data have documented favorable efficacy and safety effects of the tension-free vaginal tape (TVT) technique –19 and tThe Ethics Committee of the Medical University of Graz, Austria approved this retrospective study. The FSFI was developed as a brief, multidimensional self-report instrument for assessing key dimensions of sexual function in women. The scale consists of 19 items that assess sexual function over the past 4 weeks and yield domain scores in six areas: sexual desire, arousal, lubrication, orgasm, satisfaction, and pain. The measure was validated on an initial sample of women with female sexual arousal disorder (FSAD) and a control sample of women without sexual difficulties . Based oThe individual domain scores and full-scale score of the FSFI can be derived from the computational formula. For individual domain scores, add the scores of the individual items that comprise the domain and multiply the sum by the domain factor; add the six domain scores to obtain the full-scale score. Women were eligible for the SPARC surgery if they had predominant SUI symptoms, a positive cough stress test, and a bladder capacity >200 mL. Patients with previous failed incontinence surgery, mixed urinary incontinence (MUI), or previous gynecological surgery were included. Women with neurological findings or vaginal support defects greater than second stage according to the Pelvic Organ Prolapse Quantification system were excluded. Objective cure was defined as pad weight 0-1 g and a negative cough test in a standing position. Subjective cure was defined as no use of pads according to the micturition diary. Improvement was defined as urine loss only during cough test, a pad weight of >1–5 g, and overall patient satisfaction (by responding “Yes” to the question. Are you satisfied with the degree of urinary continence achieved after the operation?) A written informed consent was obtained from all patients. A minimum follow-up of 12 months was required for study inclusion. Concomitant gynecologic surgery or prolapse repair were not performed in our patients; we performed only SPARC operation in our patients without concomitant gynecologic surgery. We performed SPARC only after hysterectomy.P ≤ 0.05  was considered statistically significant.Statistical analyses were performed using Statistical Package for Social Sciences, version 11.5 . The mean values were analyzed using the nonparametric Wilcoxon signed rank test. Between June 2001 and March 2009, 151 women with SUI and a mean age of 60 ± 11.9 years underwent SPARC sling placement at our institution. Of these, 98 (64.9%) women completed the validated FSFI questionnaire at baseline and 94 (62.3%) women at follow-up. Mean follow-up was 4.71 ± 2.42 years. 52/98 (53.1%) women with a mean age of 58.7 ± 10.4 years were sexually active at baseline and 46/98 (46.9%) women with a mean age of 69 ± 10.9 were sexually inactive at baseline. Preoperatively sexual activity was normal (FSFI > 26.55) in 24/52 (46.2%) with a mean total FSFI score of 30 ± 2.1, and 28/52 (53.8%) showed a reduced sexual function (FSFI < 26.55) with a mean total FSFI score of 20.3 ± 5.4. Patient's characteristics are shown in P = 0.07) as well as all subdomains (P = 0.07) with the exception of orgasm (P = 0.3), showing a clear trend of deterioration of their total sexual function.33/52 (63.5%) sexual active women who had the same conditions concerning relationship and personal circumstances pre- and postoperatively were eligible for analysis at follow-up. 19/52 (36.5%) preoperatively sexual active women were excluded due to various reasons. 13/19 (68.4%) became sexually inactive  and 4/1941/46 (89.1%) of the sexually inactive women prior surgery were still sexually inactive at follow-up, 3/46 women became sexual active after being cured from SUI, and 2 women presented preoperative data only.P = 0.000) and 3.1 ± 1.3 and 1.5 ± 0.8 (P = 0.000) at follow-up, respectively.Analysis of the FSFI questionnaire subdomain desire (questions 1 and 2) at baseline showed a score of 3.4 ± 0.9 for sexual active women and 1.5 ± 0.7 for sexual inactive women  women had normal sexual function and 18/33 (54.5%) women had a reduced sexual function. At follow-up 18/33 women showed normal sexual function (54.5%) and 15/33 (45.5%) women had reduced sexual function. Three women with reduced sexual function prior surgery achieved normal sexual function postoperatively.P = 0.1) in all 33 pre- and postoperative sexual active women, as the subscores did of the various domains, with the exception of the domains desire (P = 0.05) and satisfaction (P = 0.04)  . Scores According to satisfaction 16/33, (48.5%) women showed an increase in their scores, 12 remained unchanged, and five showed a decrease in their scores. More than 50% of all pre- and postoperative sexual active women showed a higher score postoperatively . 12 womeConcerning complications, one patient showed asymptomatic vaginal sling erosion (approximately 1 mm) 4 years after surgery. Due to the small size of the lesion and the total absence of symptoms, no treatment was necessary at this stage, but annual gynaecological examination was recommended. Urinary retention was observed in one patient and significant postvoid residual (>200 mL) in three patients. These complications were successfully treated by immediate loosening of the sling. Perforation of the bladder occurred in four patients with no need of open revision.De novo urgency symptoms developed in four patients and they improved on anticholinergic medication.Although male sexual dysfunction received more investigations and attention, female sexual dysfunction remains largely underinvestigated. This fact led us to perform our study.In this study, we report the impact of the SPARC sling system on the female sexual function in women suffering from SUI. Women undergoing the SPARC sling operation experienced no deterioration of their FSFI scores. Our results do not show any deterioration of sexual function after surgery in contrary to previously reported data that sling operations may cause increased dyspareunia , 27. ProGoldstein et al.  found a Additionally, a recent study showed that midurethral slings could interfere with clitoral blood flow and subsequently clitoral erection . In contPace et al.  showed iThe SPAR-sling procedure was primarily invented to decrease organ injury, of the bowel, and lower urinary tract that sometimes occur during implantation of the TVT trocar , which aKuhn et al.  reportedUnfortunately randomized trials with sufficient power to determine which route is best regarding sexual function are missing.Of the 52 preoperative sexual active women in our study only 33 patients remained sexually active and showing the same conditions pre- and postoperatively. 13/52 women were postoperative abstinent from any sexual activity for a variety of reasons but not tape related. 4 women are divorced postoperative and perform their sexual activity by masturbation and in 2 only preoperative data are present.The majority of studies which focused on the impact of TVT procedure on the sexual function of women suggest that sexual function is not changed by the procedure, which is in agreement with our results.Improvement in sexual function may be related to an improvement in self-esteem, which would affect the partners' relationship. Sexual function is a very complex issue and a lot of different factors may influence women's sexuality including hormonal changes, medications, social situation, relationship, availability of a partner, and own health status and of the partner.Certainly, more in depth studies examining vaginal structural changes with adequate assessment of the vaginal blood flow are needed to understand the favorable changes the SPARC sling has on the sexual function. Finally, our study is limited by the lack of a control group, the low number of patients involved, and the absence of multiple postoperative follow-up sessions. These results suggest that the SPARC-sling procedure for SUI does not worsen sexual function in women. In fact, all domains of the FSFI improved after-SPARC implantation. Additional prospective studies are warranted to verify these preliminary findings and compare the impact of SPARC with that of other anti-incontinence procedures.